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Full text of "Addresses & papers, dedication ceremonies and Medical conference, Peking Union Medical College : September 15-22, 1921, Peking, China"

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DEDICATION 

PEKING UNION MEDICAL COLLEGE 

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Addresses & Papers 
DEDICATION CEREMONIES 



AND 



MEDICAL CONFERENCE 

Peking Union Medical College 



SEPTEMBER 15-22, 1921 




PEKING, CHINA 
1922 



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All Rights Reserved 



RUMFORD PRESS 
CONCORD, NEW HAMPSHIRE 



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PEKING UNION MEDICAL COLLEGE 

OFFICERS AND BOARD OF TRUSTEES 
1921 
Members of the Board 
Paul Monroe, Chairman 
J. Auriol Armitage, Vice-Chairman 
James L. Barton John R. Mott 

Arthur J. Brown Frank. Mason North 

Wallace Buttrick James Christie Reid 

Simon Flexner John D. Rockefeller, Jr. 

F. H. Hawkins George E. Vincent 

William H. Welch 

Executive Committee 
George E. Vincent, Chairman 
Arthur J. Brown Simon Flexner 

Wallace Buttrick Frank Mason North 

Secretary 

Edwin R. Embree 

61 Broadway, New Tork City 

Assistant Secretary 
Margery K. Eggleston 



ADMINISTRATIVE OFFICERS IN PEKING 

Director 
Henry S. Houghton, M.D. 

Superintendent of the Hospital 
Ralph B. Seem, M.D.* 

Assistant Superintendent of the Hospital 
T. Dwight Sloan, M.D. 

Dean of the Pre-Medical School 
William Warren Stifler, Ph.D. 

Superintendent of Nurses 
Anna D. Wolf, A.M., R.N. 

Comptroller 
James S. Hogg 

" On leave of absence from the University of Chicago. 



CONTENTS 
THE COLLEGE— HISTORY AND DESCRIPTION PAGE 

Beginning of the Work of the Rockefeller Foundation in China 3 

Activities of the China Medical Board 4 

History of Peking Union Medical College 12 

Buildings of Peking Union Medical College 14 

PROGRAM AND DELEGATES 

Program of the Medical Conference 19 

Academic Procession . 24 

Official Delegates of Educational and Scientific Bodies 25 

Members of the Medical Conference 28 

Credentials of Delegates and Messages of Felicitation 33 

DEDICATION CEREMONIES 

Invocation. The Rev. J. Leighton Stuart, D.D., President of Peking 
University 41 

Presentation of the Hospital and Medical School on Behalf of the Rocke- 
feller Foundation. George E. Vincent, Ph.D., President of the Rocke- 
feller Foundation 42 

Acceptance on Behalf of the College. Henry S. Houghton, M.D., Director 
of Peking Union Medical College 43 

Greetings on Behalf of the President of the Republic of China. His Ex- 
cellency, W. \V. Yen, Minister of Foreign Affairs 45 

Greetings on Behalf of the Ministry of the Interior. His Excellency, Chi 
Yao-san, Minister of the Interior, and S. P. Chen, M.D., Director of the 
Central Hospital, Peking 47, 48 

Greetings on Behalf of the Ministry of Education. His Excellency, Ma 
Lin-yi, Minister of Education 51 

Response for the China Medical Board. Roger S. Greene, Resident Director 
of the China Medical Board 52 

Response for the Rockefeller Foundation. John D. Rockefeller, Jr., Chair- 
man of the Board of Trustees of the Rockefeller Foundation 57 

Address at the Reception at the President's Palace. His Excellency, Hsu 
Shih-ch'ang, President of the Republic of China 67 

EVENING ADDRESSES 

Medical Education in China : A Survey and Forecast. Edward H. Hume, 
M.D., Dean of the Hunan-Yale College of Medicine, Changsha 71 

Medical Education in the Dutch East Indies. A. de Waart, M.D., Direc- 
tor of the Government Medical School, Batavia 94 

An Adventure in Public Health. George E. Vincent, Ph.D 101 



viii CONTENTS 

Methods of Visualizing Modern Health Ideas. W. W. Peter, M.D., Sec- 
retary of the Council on Health Education in China, Shanghai 103 

Biochemistry in Retrospect and in Prospect. A. B. Macallum, Sc.D., 
F.R.S., Professor of Biochemistry, McGill University, Montreal no 

The Search for the Ideal in Hospital Organization. S. S. Goldwater, M.D., 
Director of Mount Sinai Hospital, New York 126 

Hookworm Control as a Promoter of Public Health Agencies. Victor G. 
Heiser, M.D., Director for the East, International Health Board of the 
Rockefeller Foundation 142 

Introduction of Dr. William H. Welch. General Leonard Wood, M.D., 
Governor General of the Philippine Islands 146 

The Advancement of Medicine and Its Contribution to Human Welfare. 
William H. Welch, M.D., Director of the School of Hygiene and Public 
Health, Johns Hopkins University 148 

MORNING ADDRESSES 

Salutatory. George E. de Schweinitz, M.D., Professor of Ophthalmology, 
University of Pennsylvania; President of the American Medical Associa- 
tion 165 

Concerning the Evolution of Some of the Visual Phenomena of Pituitary 
Body Disorders. George E. de Schweinitz, M.D 167 

Plague in the Orient with Special Reference to the Manchurian Outbreaks. 
Wu Lien Teh, M.D., Head of the North Manchurian Plague Prevention 
Service 186 

The Clinical Importance of the Vital Capacity of the Lungs. Francis W. 
Peabody, M.D., Associate Professor of Medicine, Harvard University. . 208 

The Origin of Blood-Cells. Florence R. Sabin, M.D., Professor of His- 
tology, Johns Hopkins University 228 

Osteomyelitis. Theodore Tuffier, M.D., Professor of Clinical Surgery, 
University of Paris 247 

The Present Status and Future Problems of Chemotherapy. Sahachiro 
Hata, M.D., Kitasato Institute for Infectious Diseases, Tokyo 250 

CLINICAL SECTIONS 
DEPARTMENT OF GENERAL MEDICINE 

Syphilis. H. Jocelyn Smyly, M.D., Associate in Medicine, Peking Union 
Medical College 269 

Symposium on Kala Azar. Oswald H. Robertson, M.D., Associate in 
Medicine, Peking Union Medical College, Richard H. P. Sia, M.D., 
Charles W. Young, M.D., John H. Korns, M.D.,— All of the Staff of 
the Peking Union Medical College 270 

Electrocardiography. Franklin C. McLean, M.D., Professor of Medi- 
cine, Peking Union Medical College 273 

Conference on Leprosy. Victor G. Heiser, M.D., Ruth A. Wood, of the 
Chemical Laboratory of the Peking Union Medical College, and R. M. 
Wilson, M.D., Kwangju Leper Home, Kwangju, Korea 274 



CONTENTS ix 

Conference on Sprue. H. Jocelyn Smyly, M.D., J. B. Grant, M.D., 
Associate Professor of Hygiene and Public Health, Peking Union Medical 
College, E. W. Ewers, M.D., Weihsien, Shantung, Ralph G. Mills, M.D., 
Professor of Pathology, Peking Union Medical College, R. M. Wilson, 
M.D., Samuel Cochran, M.D., Dean of the Medical School, Shantung 
Christian University, Tsinan, Shantung 276 

Tuberculosis. John H. Korns, M.D., Associate in Medicine, Peking Union 
Medical College 278 

DEPARTMENT OF GENERAL SURGERY 
(See also Sections Combined with Pathology) 

Operative Clinic: 

Radical Cure of Inguinal Hernia. Adrian S. Taylor, M.D., Professor of 

Surgery, Peking Union Medical College 283 

Demonstration: 

Balkan Frame and Apparatus for the Treatment of Fractures. George W. 
Van Gorder, M.D., Associate in Surgery, Peking Union Medical College. 285 
Skin Grafting — Thiersch and Reverdin. George Y. Char, M.D., Assistant 

in Surgery, Peking Union Medical College, and Adrian S. Taylor, M.D. 288 
Epithelioma. Frank Meleney, M.D., Associate in Surgery, Peking Union 

Medical College 289 

Discussion of Surgical Aspects of Epithelioma. Theodore Tuffier, M.D., 

and Adrian S. Taylor, M.D 296 

The Preparation and Use of Dakin's Solution. Adrian S. Taylor, M.D., 

and Theodore Tuffier, M.D 300 

Operative Clinic: 

Case 1. Ankylosis of Hip. Theodore Tuffier, M.D 305 

Case 2. Adenoma of Thyroid. Adrian S. Taylor, M.D 305 

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY 

Summary, Including: 

Operation: Vaginal Cyst. John G. Clark, M.D., Professor of Gyne- 
cology, University of Pennsylvania 309 

Demonstration: Case of Procidentia. John G. Clark, M.D 309 

Measurements of the Chinese Pelvis and the Main Forms of Contraction 
Seen in China. David E. Ford, M.D., Assistant in Obstetrics and 

Gynecology, Peking Union Medical College 309 

Causes of Uterine Hemorrhage. John G. Clark, M.D 309 

Operation for Sterility. John G. Clark, M.D 309 

Demonstration of Woo's Needle. Arthur W. T. Woo, M.D., Associate 

in Obstetrics and Gynecology, Peking Union Medical College 310 

Interesting Cases of the Year 1920-21. J. Preston Maxwell, M.D., Pro- 
fessor of Obstetrics and Gynecology, Peking Union Medical College. ... 311 
Eclampsia and Eclampsism. Sir William J. Smyly, M.D., Gynecologist of 

Adelaide Hospital, Dublin 320 

Maternity Famine Relief. Jean I. Dow, M.D., Canadian Presbyterian 
Mission, Changteh, Honan 327 



x CONTENTS 

Some Practical Aspects of Embryological Research in China. Paul H. 
Stevenson, M.D., Assistant in Anatomy, Peking Union Medical College 334 

DEPARTMENT OF PATHOLOGY 
(Including Sections Combined with Surgery) 

Present Day Aspects of Parasitology in China. Ernest C. Faust, Ph.D., 

Associate in Parasitology, Peking Union Medical College 341 

Certain Aspects of Parasitology in the Philippines. Frank G. Haughwout, 

M.D., Bureau of Science, Manila 343 

Conference on Pneumonic Plague: 
Plague Epidemic in the Chinese Eastern Railway Region in 1920-21. 
P. Lostchiloff, M.D., Chief Surgeon, and G. Tchaplik, M.D., Sanitary 

Division, Chinese Eastern Railway, Harbin 354 

Discussion. Wu Lien Teh, M.D., Charles W. Young, M.D., Assistant 
Professor of Medicine, Peking Union Medical College, William H. 

Welch, M.D 356 

Case Reports and Demonstrations: 

Case 1. Thrombosis of the Superior Petrosal Sinus and Meningitis, 
Following Acute Mastoiditis. Henry E. Meleney, M.D., Associate 

in Pathology, Peking Union Medical College 361 

Case 1. Syncytioma (Atypical Chorioma) of the Uterus, Terminated by 

Acute Peritonitis. Henry E. Meleney, M.D 363 

Tetanus. Adrian S. Taylor, M.D., George Y. Char, M.D., Carl Ten 
Broeck, M.D., Johannes H. Bauer, M.D., Samuel Cochran, M.D., 
J. Preston Maxwell, M.D., A. W. Tucker, M.D., Shanghai, Theodore 

Tuffier, M.D 369 

Pathological Problems in the Orient. William H. Welch, M.D 377 

DEPARTMENT OF OPHTHALMOLOGY 
Operative Clinic: 

Case 1. Extraction of Cataract. Harvey J. Howard, M.D., Professor 

of Ophthalmology, Peking Union Medical College 385 

Case 2. Discission of Secondary Cataract. Harvey J. Howard, M.D.. . 386 
Presentation of Cases: 

Case 1. Toxic Amblyopia. T. M. Li, M.D., Associate in Ophthal- 
mology, Peking Union Medical College 388 

Case 2. Quinine Amblyopia. Harvey J. Howard, M.D 388 

Case 3. Chronic Iritis. T. M. Li, M.D 389 

Case 4. Diminished Vision and Vitreous Opacities. Harvey J. Howard, 

M.D 390 

Discussion. Harvey J. Howard, M.D., YV. S. Thacker-Neville, M.D., 

and P. S. Soudakoff, M.D 390 

Operative Clinic: 

Complete Tenotomy and Resection in Four Different Types of Strabis- 
mus. Harvey J. Howard, M.D., and T. M. Li, M.D 392 

Interesting Cases of 1920-21. Harvey J. Howard, M.D., and T. M. Li, 
M.D 395 



CONTENTS xi 

Operative Clinic: 

Three Cases of Expression for Trachoma. Harvey J. Howard, M.D., 
and T. M. Li, M.D 399 

Presentation of Cases: 

Case 1. Tuberculous Uveitis. Harvey J. Howard, M.D 400 

Case 2. Primary Optic Atrophy. T. M. Li, M.D 401 

DEPARTMENT OF OTOLARYNGOLOGY 
Operative Clinic: 

Esophagoscopy. A. M. Dunlap, M.D., Professor of Otolaryngology, 

Peking Union Medical College 405 

Operative Clinic: 

Radical Mastoidectomy. J. Hua Liu, M.D., Assistant in Otolaryngol- 
ogy, Peking Union Medical College 406 

Operative Clinic: 

Removal of Tonsils and Adenoids. A. M. Dunlap, M.D 408 

DEPARTMENT OF NEUROLOGY 

Syphilis of the Nervous System. Andrew H. Woods, M.D., Associate 
Professor of Neurology and Psychiatry, Peking Union Medical College. . 413 



ILLUSTRATIONS 

THE COLLEGE 

Staff and Students of Peking Union Medical College frontispiece 

OPPOSITE 
PAGE 

Lockhart Hall, the Old Union Medical College, Now Used for the Pre- 

Medical School 12 

Main Entrance to the Medical School Group 12 

Physiology Building, from the Auditorium 13 

Private Patients' Building 13 

Second-Year Class in Physiology 14 

General Plan of College Showing Location of College, Hospital, and Pre- 

Medical School Buildings 14 

Machine-Shop in the Physiology Building 15 

A Part of the Academic Procession at the Dedication Ceremonies 24 

The Auditorium*. 25 

A Group of Guests and Members of the Staff at the Dedication Exercises 25 
Students' Laboratory, Physiological Chemistry, Second Floor Chemistry 

Building 112 

Private Laboratory, Department of Physiological Chemistry 113 

Kitchen for the Preparation of Chinese Food 130 

Public Ward, Department of Medicine 130 

Laundry, Second Floor of the Power-House 131 

Engine-Room with Dynamos, Pumps, Air Compressors, and Refrigerating 

Machinery 131 

Dissecting Room, Anatomy Building 228 

Terrace and Portico of Anatomy Building 229 

Bacteriological Laboratory of the Associate Professor, Department of 

Medicine 272 

Professor's Chemical Laboratory, Department of Medicine 273 

Corridor of the Out-Patient Department 284 

One of the Four Main Operating Rooms, Fourth Floor of the Dispensary 

and Hospital Laboratory Building 285 

Entrance Hall of the Nurses' Home . 310 

Demonstration Room for Classes in Practical Nursing 310 

Graduate and Student Nurses, 1921 311 

Solarium in the Private Patients' Building 311 

Autopsy Room, Pathology Building 342 

Parasitology Laboratory, Pathology Building 343 

Service Court and Pathology Building 376 

A Reading-Room in the Library 377 

South Residence Compound 402 

North Residence Compound 403 



xiv ILLUSTRATIONS 

SCIENTIFIC PAPERS opposite 

PAGE 

Pituitary Body Disorders (Figures i to 32) 176 

Optic Nerve Atrophy in Pituitary Body Adenoma (Color Plate) 180 

Fibroid of Cervix Undergoing Malignant Change (Figure 1) 316 

Fibroid Polypus Which Expanded Anterior Cervical Wall (Figure 1) 317 

Uterus and Ovaries of New-Born Fetus. The Ovaries Show a Marked 

Cystic Change (Figure 3) 318 

Uterus and Ovaries of New-Born Fetus, Normal, for Comparison with 

Figure 3 (Figure 4) 319 

Syncytioma of the Uterus (Figures 1 to 10) 368 



THE COLLEGE — HISTORY AND 
DESCRIPTION 



BEGINNING OF THE WORK OF THE ROCKEFELLER 
FOUNDATION IN CHINA 

The interest of the Rockefeller Foundation in China, shown so 
plainly in the establishment of this extensive medical center, is not 
new. As far back as 1908, the needs of the Far East had attracted 
Mr. Rockefeller's attention to such an extent that a commission was 
sent out composed of Dr. Ernest D. Burton and Dr. Thomas C. 
Chamberlin of the University of Chicago, to study the educational 
situation in China, Japan, and India. After spending several months 
in each country, this commission returned a report recommending 
the establishment at Peking of an educational institution for the 
teaching of .the natural sciences. It was proposed, however, after 
consideration, to develop the branch of medical science only, rather 
than to undertake the more extensive program. Before any action 
was taken, a second commission was sent out in 1914, this time to 
China alone, to consider the needs and opportunities for medical 
work. This group was headed by President Harry Pratt Judson of 
the University of Chicago. The other members were Dr. Francis W. 
Peabody of the Harvard Medical School and Mr. Roger S. Greene, 
then Consul General at Hankow, later appointed Resident Director 
of the China Medical Board. Their report endorsed the suggestion 
that medical work be undertaken, and outlined a program for aiding 
medical schools and hospitals. 

The China Medical Board was then formed as a branch of the 
Rockefeller Foundation. In the summer of 191 5, a third commission 
was sent out, composed of Dr. William H. Welch of the Johns Hop- 
kins Medical School, Dr. Simon Flexner of The Rockefeller Institute 
for Medical Research, Dr. Wallace Buttrick, Secretary of the Gen- 
eral Education Board, and Dr. Frederick L. Gates of The Rocke- 
feller Institute. This commission recommended the establishment 
of two medical schools, and studied in detail the opportunities pre- 
sented in Peking and Shanghai. As a result, the decision was reached 
to enter into co-operation with the Peking Union Medical College, 
whereby the China Medical Board should take over the land and 
buildings on the basis of their original cost, and provide the main- 
tenance and new construction costs. 



ACTIVITIES OF THE CHINA MEDICAL BOARD 

The purpose of the China Medical Board of the Rockefeller 
Foundation is to co-operate with other agencies in the gradual devel- 
opment of a system of scientific medicine in China. In other coun- 
tries preventive work in medicine first engaged the main efforts of 
the Foundation, since the fostering of public health presents the pros- 
pect of far larger results in the welfare of nations and individuals, 
for the expenditure of any given sum, than an equal expenditure of 
effort and money on the treatment of the sick. In China, however, 
several factors have contributed to defer the initiation of direct 
activities in hygiene and preventive medicine by the Rockefeller 
Foundation. 

In the first place systematic protection of the public health is 
properly a government function; and while private agencies can 
sometimes give valuable aid in such activities, their efforts are 
usually most effective when subordinated to a carefully conceived 
program of some governmental unit, such as a province or munici- 
pality. In the disturbed political conditions now prevailing through- 
out China, with frequent changes in the government, and with the 
authorities preoccupied as they are with other more pressing prob- 
lems, the prospects for the early development of public health work 
on a large scale have not been encouraging. A second difficulty 
lies in the fact that confidence in scientific medicine is not sufficiently 
widespread to insure on the part of the people the co-operation 
necessary for the most effective work. Furthermore, it is clear that 
while much of preventive medicine as it is known in the West can be 
applied immediately in China, the conditions to be dealt with, 
whether biological, social, or economic, are so different from those 
in the West that it is important to precede any large effort in public 
health by a period of careful study of local conditions, in order that 
the measures undertaken may be properly adapted. Finally it must 
be admitted that a highly trained personnel is as necessary for a 
public health program as for the manning of hospitals, and that the 
number of doctors now available in China is not sufficient for any 
considerable extension of either kind of work. 



HISTORY AND DESCRIPTION 5 

The problem of medical education was therefore indicated as 
that which first demanded attention. With this in mind the following 
lines of activity have suggested themselves: 

1. Pre-medical education, through strengthening of science 
courses in colleges. 

1. Medical education. 

a. Undergraduate courses. 

b. Training of investigators, teachers, and clinical specialists 

through prolonged graduate courses and through practical 
work under proper guidance. 

c. Stimulating of private practitioners and missionary doctors, 

both foreign and Chinese, by short graduate courses. 

3. Medical research, especially with reference to problems of the 
Far East. 

4. Improvement of hospitals as training centers for internes and 
nurses, as models for imitation, as indispensable adjuncts to the 
practising physician, and as a means of popular education. 

5. Diffusion among the Chinese people of a knowledge of modern 
medicine and public health. 

6. Fostering of professional ethics through the development of 
character and ideals of service. 

The most important contribution of the China Medical Board has 
been the reorganization of the Peking Union Medical College, which 
has included the gathering of a large staff of teachers, nurses, and 
administrative officers, recruited in part from institutions in the 
United States, Canada, and Great Britain, in part from among per- 
sons with considerable experience in medical missionary work in 
China, and now in increasing numbers from well-trained Chinese. 
The staff included in 1921 fifteen pre-medical teachers, fifty-seven 
teachers in the Medical School, thirty-one nurses, and forty-eight 
administrative and technical officers. Of these, one hundred and 
twenty-three are foreigners and twenty-three Chinese trained 
abroad. New medical school buildings, capable of accommodating 
classes of twenty-five, to be increased by some adjustments to fifty, 
and a 250-bed hospital, have just been finished and are now in use. 

A Pre-Medical School with a three-year course, receiving middle 
school graduates with a good knowledge of English, has been estab- 



6 PEKING UNION MEDICAL COLLEGE 

lished to give the prospective medical students thorough prepara- 
tion in physics, chemistry, biology, English, and Chinese. Students 
are also required to study either French or German during this pe- 
riod. The registration at the beginning of the school year 1920-21 
was twenty-seven in the first year, twenty-three in the second, and 
nine in the third. The maintenance for the time being of this pre- 
paratory school has appeared to be a necessity, for although there 
are some colleges in China giving good courses in one or two of the 
sciences, some of the best institutions are very weak in these sub- 
jects, and none of them have thus far presented for admission to the 
Medical School students properly prepared in all three sciences. At 
the same time an attempt has been made to help other institutions 
to give better instruction in physics, chemistry, and biology. Direct 
grants have been made for this purpose to St. John's University, 
Fukien Christian University, Canton Christian College, and Yale- 
in-China, to be used towards both buildings and staff, while a small 
part of a grant to the Shantung Christian University Medical 
School has also been used for the pre-medical courses. 

The Medical School proper of the Peking Union Medical College 
was opened in the fall of 191 9, and there were last year thirteen 
students in the first and second year classes. The higher class began 
its clinical studies in the fall of 1921. Side by side with the under- 
graduate classes a number of Chinese and foreign doctors have been 
receiving instruction, some being admitted to regular undergraduate 
courses, a few attending special courses for graduates, and a larger 
number entering the clinics for practical work in the various depart- 
ments. During the past twelve months there have been seventy-two 
such persons enrolled at different times, some of whom hold appoint- 
ments as internes, residents, or assistants. The allowances paid for 
most of these positions are so much lower than those prevailing out- 
side, even in mission institutions, that the educational significance 
of the service is clearly emphasized, and at the same time the danger 
is avoided of accustoming the young graduates to salaries larger 
than most of them could get elsewhere. For graduate students not 
holding regular appointments in the college the China Medical 
Board provides a limited number of fellowships, sufficient to cover 
tuition and maintenance, and in some cases also travelling expenses. 



HISTORY AND DESCRIPTION 7 

In a few cases very encouraging reports have been received as to the 
value of this graduate training, and now that the college has moved 
into its new quarters and has the larger part of its staff at work, 
it should be possible to render better service in this as in other 
branches of its activities. The special graduate courses for prac- 
titioners are being given mainly at the Chinese New Year and during 
the summer vacation. 

A most important branch of the work of the College is the Nurses' 
Training School, which hopes to give to Chinese young women an 
education in nursing comparable to that offered in our best hospitals 
in the United States. Middle school graduation, or its equivalent, and 
a working knowledge of English are required for admission to the 
four-year course. The first year is devoted to work in the classroom 
and laboratory, and includes science courses in the Pre-Medical 
School. In the remaining years practical work in the wards is com- 
bined with instruction in theory. The aim is to turn out nurses who 
shall be prepared to take positions of responsibility in teaching and 
in other hospitals on an equality with nurses trained abroad. The 
fact that many institutions have been unable to secure foreign nurses, 
even when their support was assured, indicates the urgent need for 
Chinese of equal training, whose broad educational background will 
enable them to command the respect which the nursing depart- 
ment of a hospital must have if it is to play its proper part. Grad- 
uate students will be admitted also to the Nurses' Training School, 
and some of these, who have a good command of English, may be 
given scholarships for study abroad, if the quality of their work at 
the Peking school seems to justify the expense. Arrangements have 
recently been made with the women's department of Peking Uni- 
versity for a combined course, the first years in the University and 
the latter part in the College Hospital, leading to the bachelor's 
degree in Peking University. 

A Department of Dietetics has been organized and chemical 
studies of all important Chinese foods are being made, in order that 
hospital diets may be intelligently selected. Some instruction in 
dietetics is given to the pupil nurses, and informal courses have been 
arranged for others desiring to specialize in this subject. 

While devoting its energies and its resources mainly to the Peking 



8 PEKING UNION MEDICAL COLLEGE 

school, the Board has been much interested also in the development 
of other institutions. In particular, grants have been made to the 
Hunan-Yale College of Medicine, and to the Shantung Christian 
University School of Medicine. Like the Peking school, the Yale 
school teaches in English, while Shantung University teaches in 
Chinese. Small grants have also been made to the Pennsylvania 
Medical School of St. John's University, and to the National Medi- 
cal College, a Government school at Peking. The Hunan and Shan- 
tung schools have also been able to secure much more support than 
before from sources other than the China Medical Board, and 
though they still have many urgent needs, they have made such 
good use of their funds and have worked so constantly for higher 
standards that they should undoubtedly look forward to a future of 
great usefulness. Teachers from these schools on furlough have held 
junior teaching appointments in some of our best American medical 
schools, thus gaining useful experience and at the same time helping 
to win recognition for the institutions from which they come. In 
many cases the China Medical Board has given fellowships to teach- 
ers in medical schools other than the Peking school in order to enable 
them to carry on systematic study in their respective departments 
during their furlough years. 

The medical profession of China has thus far labored under the 
serious handicap of not having any common language medium for 
scientific intercourse. There has been no generally accepted medical 
terminology in Chinese; and the groups trained abroad or in China 
under the influence of different foreign nationalities naturally cling 
to the language of their teachers, having no other satisfactory means 
of expression. At the instigation of the China Medical Missionary 
Association a joint terminology committee has been organized, 
which has now made great progress in preparing an official terminol- 
ogy for the medical and pre-medical sciences. Government institu- 
tions are now taking a leading part in the work, and the new terms 
are to be published with the sanction of the Ministry of Education. 
The China Medical Board has assisted in this enterprise and in the 
work of producing a medical literature in Chinese, through grants to 
the China Medical Missionary Association and the National Medi- 
cal Association of China. 



HISTORY AND DESCRIPTION 9 

No especial institution devoted entirely to research has been con- 
templated, but it is expected that teachers in the medical schools 
will in time be able to make important original contributions to 
medical science, as it has been the intention in the Peking school to 
give the teachers some opportunity for such work. The China Medi- 
cal Missionary Association also has a research committee with which 
the teachers at Peking co-operate. Through this organization it may 
be possible, by the co-ordination of the efforts of a wide circle of 
independent workers, to secure some results of value. 

Much attention has been devoted to the raising of hospital 
standards in China, for the work of medical education may be 
largely wasted unless there are opportunities for young doctors to 
practice their profession under favorable circumstances. Similar 
waste is often observed in the case of Chinese with a highly techni- 
cal training in other branches, who return to their native land to 
find no suitable employment in their specialties, and no older col- 
leagues with long practical experience to give them the needed 
guidance. The leading position taken by the missionary societies in 
medical work in China has been recognized and the attempt has 
been made to co-operate with them by strengthening the hands of 
their doctors and nurses, thus conserving a most important force for 
medical progress. It was obviously impossible to co-operate effec- 
tively with all the three hundred or more medical mission centers 
in China, and the general policy has therefore been to aid those 
hospitals near the principal medical schools and to establish an 
intimate though wholly informal relationship between them and the 
schools. Preference has also been given to institutions located in 
important cities with good prospects of securing local support, and 
to those already possessing a good nucleus in staff, equipment, or 
buildings, as it was felt that in such cases the relatively small con- 
tributions which the China Medical Board could make would pro- 
duce the largest results. The aid given has taken the form of con- 
tributions to the support of additional staff, to general maintenance 
expenses, and to improvements in buildings and equipment. Of late 
such contributions have not amounted to more than one-half of the 
total sum required for the proposed additions and improvements, 
the remainder being supplied by the missions. Up to June 30, 1921, 



io PEKING UNION MEDICAL COLLEGE 

grants of this kind had been made to thirty mission hospitals and 
one purely Chinese institution. It is likely that the more urgent 
claims of strictly educational institutions will make it impossible 
hereafter to devote as large sums to this branch of the work as in 
the past. In any case the future development of these hospitals must 
depend mainly on their ability to enlist the support of the communi- 
ties which they are trying to serve. 

Not only have the mission contributions to these hospitals in- 
creased, but in many cases the improvements made have rendered 
it possible to secure added Chinese support. The China Medical 
Board has also given to a large number of doctors in mission hospital 
work, grants towards the cost of graduate study while they are on 
furlough. The great work that missionary doctors have done in the 
relief of immediate suffering speaks for itself and needs no further 
comment. While the ordinary mission hospital has many serious 
deficiencies, it has one great element of strength, not often shared by 
equally small institutions at home, in that it has the full time of one 
and sometimes of two or three experienced doctors devoted entirely 
to its interests, and the staff usually live so near the hospital that 
the patients have at least one resident physician constantly on call. 
One of the most important achievements of the mission hospital has 
been the creation of popular confidence in Western medicine, which 
has enabled the physician in times of epidemics to assist in the pro- 
tection of the people far more effectively than he could otherwise 
have done. In places where there have been no hospitals, popular 
distrust has made effective campaigns against plague and other 
epidemics extremely difficult and often impossible. Appeals to mis- 
sion doctors for help in such emergencies are constantly becoming 
more common, and their advice is frequently sought on matters of 
hygiene in local government institutions. 

Up to the present time no separate effort has been made by the 
China Medical Board in the matter of popular education in public 
health matters. Much has been done by individual physicians, and 
by the China Medical Missionary Association in co-operation with 
other bodies, and in the future the medical schools will doubtless be 
able to assist materially. 

While the China Medical Board has now been in existence nearly 



HISTORY AND DESCRIPTION 11 

seven years, it is still one of the youngest of the many foreign organ- 
izations at work in this country. Coming as it does into a well-pre- 
pared field and enjoying the friendly co-operation of so many who 
share the same interests, it hopes to make in time, with its growing 
experience, a helpful contribution to the progress of the great 
Chinese people. 



HISTORY OF PEKING UNION MEDICAL COLLEGE 

Medical missionary work in Peking commenced with the arrival 
of William Lockhart of the London Missionary Society in 1861. 
Previous to that time, Lockhart had worked in Macao, Shanghai, 
and Chusan. He opened a small dispensary and out-patient clinic 
near the British Legation, in Peking. After three years he was suc- 
ceeded by Dr. Dudgeon, who for many years carried on a vigorous 
campaign directed toward the introduction of Western medicine into 
China. The work slowly progressed until the time of the Boxer 
rising, when all the buildings and the plant were destroyed. 

After the Boxer rising, when the need for constructive and educa- 
tional work on a broader basis was brought home to all the friends 
of China, the first attempt was made to establish a school of medi- 
cine on modern lines in Peking. In 1906, the London Missionary 
Society was joined by two others in the founding of a union school 
and shortly after, three other societies joined the Union, so that the 
missions concerned were six in number: the London Missionary So- 
ciety, the American Board of Commissioners for Foreign Missions 
(Congregational), the American Presbyterian Board, the American 
Methodist Episcopal Board, the Society for the Propagation of the 
Gospel, and the Medical Missionary Association of London. The 
first class was graduated in 191 1, just fifty years after the com- 
mencement of medical mission work by Dr. Lockhart in Peking. 

This Union Medical College was the first medical college to be es- 
tablished in China by the combination of both British and American 
medical men, and through the co-operation of missionary societies 
representing different religious denominations. Its organizer was 
Dr. Thomas Cochrane of the London Missionary Society, who was 
fortunate in obtaining the patronage and financial support of the 
Empress Dowager, and many of the leading Chinese officials. He 
also received invaluable assistance from such men as the late Sir 
Robert Hart, Sir Ernest Satow, and Dr. Douglas Gray. Dr. Coch- 
rane, whose home is now in London, was among the guests at the 
dedication ceremonies of the new buildings of the Peking Union 
Medical College, held in Peking, from September 15 to 12, 1921. 




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HISTORY AND DESCRIPTION 13 

The College was early recognized by the Chinese Government. 
The Board of Education gives a special diploma to all graduates and 
for some years certain government departments made annual grants 
towards the support of the institution. A very able group of men was 
secured as members of the teaching staff. Among these were the late 
Dr. H. V. Wenham, a man of exceptional charm and brilliant gifts, 
who came to China with the one aim in life of helping in the founda- 
tion of a modern medical school; Dr. J. G. Gibb and Dr. J. M. Sten- 
house of England, and Dr. Francis J. Hall of America; all of them 
men to whom the cause of medical education in China owes a large 
debt of gratitude. 

The teaching prior to the reorganization was in Chinese. Some of 
the graduates and students have distinguished themselves by public 
service in times of emergency. Two of the senior students laid down 
their lives for their country in the great plague epidemic in 19 10, and 
during the Revolution of 191 1 no fewer than thirty-two students 
were engaged in Red Cross work. 

The College was slowly progressing, when in 19 14 the Rockefeller 
Foundation despatched its commission to China to study the ques- 
tion of medical education there. As a final result the China Medical 
Board purchased the entire plant and arranged for the complete 
reorganization of the school under its present charter from the 
Regents of the University of the State of New York. 



BUILDINGS OF PEKING UNION MEDICAL COLLEGE 

The buildings of Peking Union Medical College and Hospital 
are located on San Tiao Hutung, between the Hatamen Ta Chieh 
and the Wang Fu Ching Ta Chieh, in the property known as the 
Yii Wang Fu, which comprises approximately ten acres of land. An 
attempt has been made to harmonize the buildings with the great 
architectural monuments of Peking by adopting as nearly as 
possible Chinese forms for the exteriors, with such modifications as 
were made necessary by the practical purposes for which the build- 
ings were to be used. The most striking features of this treatment 
are the curved roofs of green tile, with conventional decorations of 
the eaves in colors, and the entrance courts designed after the model 
of the old temples and palaces. Fourteen buildings, designated by 
the letters of the alphabet from A to N inclusive, comprise the 
main group. Brief descriptions follow: 

A. Auditorium: first floor — the auditorium with a seating capacity of 350 and 
an entrance hall for use as a social center; second floor — a social hall with serving 
room adjoining, and the offices of the Department of Religious and Social Work. 

B. Anatomy Building: museum, classrooms, laboratories, and offices. 

C. Chemistry Building: laboratories and classrooms, the Director's offices, the 
Library. 

D. Physiology and Pharmacology Building: laboratories, lecture-rooms, offices. 

E. Private Patients' Building: basement — European kitchens, stores, staff 
dining-room; first floor — office of Dietitian, living quarters of Assistant Dietitian, 
and certain other women members of the Hospital staff; second and third floors 
— rooms for private patients. 

F. Administration Building: first floor — offices of the hospital administration; 
second floor — house officers' quarters. 

G. Surgical Ward Building: three floors, each containing a twenty-five-bed 
unit; hospital supply storage in basement. 

H. Medical Ward Building: three floors, each containing a twenty-five-bed 
unit; general stores in basement. Provision storage in corridor of basement. 

I. Pathology Building: basement — autopsy suite, lecture-room, morgue, 
pathological specimen storage; first floor — Central Pathological Laboratory, 
Public Health, Parasitology, Museum, students' laboratory; second floor — 
laboratories of Bacteriology and Pathology, media supply division, research labo- 
ratories; third floor — laboratories of Chemical Pathology now used for study of 
Chinese foods, Department of Illustration and Photography, isolation ward for 
contagious diseases. 




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Hospital, and Pre-Medical School Buildings 




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HISTORY AND DESCRIPTION 15 

J. Out-Patient Building: basement — kitchens for Chinese food, refrigerators, 
staff dining-rooms, out-patient clinics of Otolaryngology and Ophthalmology; first 
floor — out-patient clinics of Medicine and Surgery; second floor — Department 
of Roentgenology, laboratories for clinical diagnosis, classrooms and lecture- 
room for general use; third floor — clinical research laboratories and department 
offices; fourth floor — operating suites. 

K. Admittance Building: basement — the Pharmacy workrooms, the admit- 
ting wards; first floor — Pharmacy, out-patient department admitting offices, 
out-patient clinics of the Departments of Obstetrics and Gynecology and of 
Pediatrics, clinical record-room ; second and third floors — wards for Pediatrics, 
Orthopedics, Obstetrics and Gynecology. 

L. Nurses' Home, including quarters for nurses, classrooms, and laboratories. 

M. Power-House, including the laundry and quarters for domestics. 

N. Animal House, offices of the Stores Department, including the receiving 
rooms. 

Across a narrow street from the power-house are located the gas 
plant, machine shops, woodworking and paint shops, the garage, 
and a large storehouse. 

Lockhart Hall, facing on Hatamen Street, houses the pre-medical 
departments: Biology, Chemistry, Physics, and Modern Languages, 
with their library. The Oliver Jones Dormitory, adjoining Lockhart 
Hall, has been used as the men's dormitory, but will in the autumn 
of 1922 become the dormitory for women students. When this 
change is made, the men students will take up quarters in the build- 
ing formerly known as the Hsin Kai Lu Hospital, which is being re- 
modeled for their use. 

A picturesque group of Chinese houses in the Ying Compound is 
now used as quarters for the women students and three foreign 
women members of the staff. 

Thirty-six residences, equipped with modern conveniences, have 
been provided for members of the staff, most of them grouped in two 
large enclosures known as the North and South Compounds, which 
are located within a few minutes' walk of the Medical School. 

The total area developed for the use of the Peking Union Medical 
College, including the residence areas, is 22.6 acres. 

MECHANICAL EQUIPMENT 

There are four 250 horse-power Babcock and Wilcox boilers, 
equivalent to 1,000 horse-power, which supply steam power and heat 
throughout the institution. 



16 PEKING UNION MEDICAL COLLEGE 

The institution is furnished with light and power by three elec- 
tric generators, with generating capacity of 375 kilowatts. 

Distilled drinking water is furnished throughout the buildings. 

Hot and cold water are supplied directly from the engine-room. A 
water-softening plant is being installed, as the local water is very 
hard. 

Refrigeration and electrically controlled hot-rooms are distributed 
throughout the institution, and each laboratory is supplied with hot 
water, cold water, gas, compressed air, low and medium pressure 
steam, no- volt direct current, 220-volt direct current, and in some 
laboratories 4-volt experimental current. 

The institution has its own private telephone exchange with ap- 
proximately 200 telephones in use, being connected with the outside 
switchboard by 10 trunk lines. 

The hospital buildings are ventilated by means of electrically 
driven exhaust fans designed to change the air in each of the rooms 
from three to five times an hour, depending upon the speed of the 
fan. 

Sewage systems have been provided for the entire institution. 
Sewage is pumped from the third section of the septic tank to the 
main city sewers by automatically controlled pumps. 

Garbage and refuse are disposed of through an incinerator on the 
property. 

The power laundry on the second floor of M Building is at present 
handling 3,000 pieces daily. 



PROGRAM AND DELEGATES 



PROGRAM OF THE MEDICAL CONFERENCE 



Morning 

9-1 1 

11:30-12:15 



Afternoon 

2-5 

5-7 

Evening 
9-10 



THURSDAY, September 15, 1921 

Registration 
Address: 

Salutatory. Dr. George E. de Schweinitz 

Concerning the Evolution of Some of the Visual Phenomena of 
Pituitary Body Disorders. Dr. George E. de Schweinitz 

Inspection of Plant 
Reception and Tea 

Address : 

Medical Education in China: A Survey and Forecast. Dr. Ed- 
ward H. Hume 



Morning 
9:30-11 



11:30-12:15 



Afternoon 

2-5 



Evening 
9-10 



FRIDAY, September 16, 1921 

Clinical Sections: 

General Medicine. Syphilis. Dr. H. Jocelyn Smyly 

General Surgery. Operative Clinic: Radical Cure of Inguinal 

Hernia. Dr. Adrian S. Taylor 
Obstetrics and Gynecology. Interesting Cases of the Year 1920-21. 

Dr. J. Preston Maxwell 
Pathology. Present Day Aspects of Parasitology in China. Dr. 

Ernest C. Faust 
Ophthalmology. Operative Clinic: Case 1. Extraction of Cata- 
ract; Case 2. Discission of Secondary Cataract. Dr. Harvey 

J. Howard 
Otolaryngology . Operative Clinic: Esophagoscopy. Dr. A. M. 

Dunlap 
Address : 

Plague in the Orient with Special Reference to the Manchurian 

Outbreaks. Dr. Wu Lien Teh 

Sightseeing: 

Coal Hill and Pei Hai 
Confucian and Lama Temples 
Tung Yueh Taoist Temple 

Addresses: 

Medical Education in the Dutch East Indies. Dr. A. de Waart 
An Adventure in Public Health. Dr. George E. Vincent 

19 



20 



PEKING UNION MEDICAL COLLEGE 



Morning 
9:30-11 



11:30-12:15 



Afternoon 

2-5 

Evening 

9-10 



SATURDAY, September 17, 1921 

Clinical Sections: 

General Medicine. Symposium on Kala Azar. Dr. Oswald H. 

Robertson and Others 
General Surgery. Demonstration: Balkan Frame and Apparatus 

for the Treatment of Fractures. Dr. George W. Van Gorder 

Skin grafting — Thiersch and Reverdin. Dr. George Y. Char 

and Dr. Adrian S. Taylor 
Obstetrics and Gynecology. Operation: Vaginal Cyst. Dr. John 

G. Clark 

Demonstration: Case of Procidentia. Dr. John G. Clark 
Pathology. Certain Aspects of Parasitology in the Philippines. 

Dr. Frank G. Haughwout 
Ophthalmology. Presentation of Cases: 

Case 1. Toxic Amblyopia. Dr. T. M. Li 

Case 2. Quinine Amblyopia. Dr. Harvey J. Howard 

Case 3. Chronic Iritis. Dr. T. M. Li 

Case 4. Diminished Vision and Vitreous Opacities. Dr. 

Harvey J. Howard 

Discussion. Dr. Harvey J. Howard, Dr. W. S. Thacker- 

Neville, and Dr. P. S. Soudakoff 
Otolaryngology. Operative Clinic: Radical Mastoidectomy. 

Dr. J. Hua Liu 
Address : 
The Clinical Importance of the Vital Capacity of the Lungs. 

Dr. Francis W. Peabody 

Reception at the President's Palace by President and Madame Hsu 

Address : 

Methods of Visualizing Modern Health Ideas (Illustrated by 
Motion Pictures). Dr. W. W. Peter 



Morning 
10:30 

Evening 
9-10 



SUNDAY, September 18, 1921 

Church Service: 

Sermon by the Rt. Rev. L. H. Roots, D.D. 

Organ recital. Mr. Ernest Hall 
Program 

Melodie Religieuse 
First Sonata 
Allegro moderato e serioso 
Adagio 

Andante recitando 
Allegro assai vivace 



Henri Ravina 

Mendelssohn 



PROGRAM AND DELEGATES 



21 



Priere et Berceuse Guilmant 

Tenor Solo from the Oratorio, " Elijah " Mendelssohn 

Recitative, "Ye people rend your hearts" 

Air, "If with all your hearts" 

Mr. D. W. Salisbury 

Prelude in C sharp minor Rachmaninoff 
Romance in D flat \ , . TT 

Andantino in D flat / Edwm R Lemare 

Offertoire Lefebure-Wely 



Morning 
9:30-11 



MONDAY, September 19, 1921 



Afternoon 
4-5:30 



Evening 
9-10 



Electrocardiography. Dr. Franklin C. 



Theo- 



Clinical Sections: 
General Medicine. 

McLean 
General Surgery. Epithelioma. Dr. Frank Meleney 

Discussion of Surgical Aspects of Epithelioma. Dr. 

dore Tuffier and Dr. Adrian S. Taylor 
Obstetrics and Gynecology. Measurements of the Chinese Pelvis 

and the Main Forms of Contraction Seen in China. Dr. 

David E. Ford 

Eclampsia and Eclampsism. Sir William J. Smyly, M. D. 
Ophthalmology. Operative Clinic: Complete Tenotomy and 

Resection in Four Different Types of Strabismus. Dr. Har- 
vey J. Howard and Dr. T. M. Li 
Otolaryngology. Operative Clinic: Removal of Tonsils and 

Adenoids. Dr. A. M. Dunlap 

Dedication Ceremonies: 

Invocation. The Rev. J. Leighton Stuart, D.D. 

Presentation of the Hospital and Medical School on Behalf of 
the Rockfeller Foundation. President George E. Vincent 

Acceptance on Behalf of the College. Dr. Henry S. Houghton 

Greetings on Behalf of the President of the Republic of China. 
His Excellency, W. W. Yen 

Greetings on Behalf of the Ministry of the Interior. His Ex- 
cellency, Chi Yao-san and Dr. S. P. Chen 

Greetings on Behalf of the Ministry of Education. His Excel- 
lency, Ma Lin-yi 

Response for the China Medical Board. Mr. Roger S. Greene 

Response for the Rockefeller Foundation. Mr. John D. Rocke- 
feller, Jr. 



Address: 

Biochemistry in 
Macallum 



Retrospect and in Prospect. Dr. A. B. 



11 



PEKING UNION MEDICAL COLLEGE 



Morning 
9:30-11 



11:30-12:15 

Afternoon 

2-5 



Evening 
9-10 



TUESDAY, September 10, 1921 

Clinical Sections: 

General Surgery. The Preparation and Use of Dakin's Solution. 
Dr. Adrian S. Taylor and Dr. Theodore Tuffier 

Obstetrics and Gynecology . Causes of Uterine Hemorrhage. Dr. 
John G. Clark 
Operation for Sterility. Dr. John G. Clark 

Pathology. Conference on Pneumonic Plague. Plague Epi- 
demic in the Chinese Eastern Railway Region in 1920-21. 
Dr. P. Lostchiloff and Dr. G. Tchaplik 

Discussion. Dr. Wu Lien Teh, Dr. C. W. Young, and Dr. 
William H. Welch 

Case Reports and Demonstrations. Case 1. Thrombosis of 
the Superior Petrosal Sinus and Meningitis, Following Acute 
Mastoiditis; Case 2. Syncytioma (Atypical Chorioma) of the 
Uterus, Terminated by Acute Peritonitis. Dr. Henry E. 
Meleney 

Ophthalmology . Interesting Cases of 1920-21. Dr. Harvey J. 
Howard and Dr. T. M. Li 

Neurology. Syphilis of the Nervous System. Dr. Andrew H. 
Woods 
Address: 

The Origin of Blood-Cells. Dr. Florence R. Sabin 



on Leprosy. Dr. Victor G. 



Clinical Sections: 

General Medicine. Conference 
Heiser and Others 
Sightseeing: 

Coal Hill and Pei Hai 

Confucian and Lama Temples 

Temples of Heaven and of Agriculture 

Address: 
The Search for the Ideal in Hospital Organization. 
Goldwater 



Dr. S. S. 



Morning 
9:30-11 



WEDNESDAY, September 21, 1921 

Clinical Sections: 

General Surgery and Pathology. Tetanus. Dr. Adrian S. Tay- 
lor, Dr. Carl Ten Broeck, Dr. Johannes H. Bauer, and Others 

Obstetrics and Gynecology. Maternity Famine Relief. Dr. Jean 
I. Dow 
Demonstration of Woo's Needle. Dr. Arthur W. T. Woo 

Ophthalmology. Operative Clinic: Three Cases of Expression 
for Trachoma. Dr. Harvey J. Howard and Dr. T. M. Li 

Neurology. Syphilis of the Nervous System. Dr. Andrew H. 
Woods 



PROGRAM AND DELEGATES 



*3 



11:30-12:15 Address: 

Osteomyelitis. Dr. Theodore Tuffier 



Afternoon 

2-5 



Evening 
9-10 



Clinical Sections: 

General Medicine. Conference on Sprue. Dr. H. Jocelyn 
Smyly and Others. 
Sightseeing: 

Temples of Heaven and of Agriculture 

Museum and Central Park 

Lung Fo Ssu and Other Markets 

Address: 
Hookworm Control as a Promoter of Public Health Agencies. 
Dr. Victor G. Heiser 



Morning 
9:30-11 



11:30-12:15 



Afternoon 

2 -5 



Evening 
9-10 



THURSDAY, September 22, 1921 

Clinical Sections: 

General Medicine. Tuberculosis. Dr. John H. Korns 

General Surgery. Operative Clinic: 

Case 1. Ankylosis of Hip. Dr. Theodore Tuffier 
Case 2. Adenoma of Thyroid. Dr. Adrian S. Taylor 

Obstetrics and Gynecology. Some Practical Aspects of Embry- 
ological Research in China. Dr. Paul H. Stevenson 

Pathology. Pathological Problems in the Orient. Dr. William 
H. Welch 

Ophthalmology . Presentation of Cases : 

Case 1. Tuberculous Uveitis. Dr. Harvey J. Howard 
Case 2. Primary Optic Atrophy. Dr. T. M. Li 
Address: Some Newer Aspects of Uveal Tract Disorders 
and Therapeutic Measures for Their Relief. Dr. George E. 
de Schweinitz 
Address : 

The Present Status and Future Problems of Chemotherapy. 
Dr. Sahachiro Hata 

Sightseeing: 

Observatory and City Hall 
Museum and Central Park 
Western Hills and Pi Yun Ssu 

Address : 

Introduction of Dr. William H. Welch. General Leonard 

Wood, M.D. 
The Advancement of Medicine and Its 

Human Welfare. Dr. William H. Welch 



Contribution to 



ACADEMIC PROCESSION 

September 19, 1921 



Mr. John D. Rockefeller, Jr. 

Mr. Roger S. Greene 

Dr. S. P. Chen 

His Excellency, Chi Yao-san 

The Rev. J. Leighton Stuart 

Sir Beilby Alston 

Dr. William H. Welch 

Dr. Paul Monroe 

Mr. F. H. Hawkins 

Dr. James L. Barton 

Dr. J. A. Armitage 

Mr. Edwin R. Embree 

Dr. Francis W. Peabody 

Dr. Thomas Cochrane 

Dr. Victor G. Heiser 

Dr. Robert T. Leiper 

Dr. Sahachiro Hata 

Dr. S. S. Goldwater 

Dr. F. L. Hawks Pott 

Dr. A. A. Gilman 

Mrs. Lawrence Thurston 

Dr. Edward H. Hume 

Dr. Warren Stuart 

Dr. E. W. Wallace 

Dr. Peder N. Pedersen 

Dr. Kuo Ping-Wen 

Dr. P. C. King 

Dr. Chang Po-Ling 

Dr. Kenyon Butterfield 

Dr. F. D. Gamewell 

His Excellency, The Minister for 

His Excellency, The Minister for 

Bishop C. P. Scott 

Bishop F. F. Keeney 

Dr. C. C. Wong 

Dr. D. E. Gossard 

Dr. Frank G. Haughwout 

Dr. Way-Sung New 

Dr. Henry S. Houghton 

His Excellency, W. W. Yen 

and the Faculty of 



Dr. W. T. Watt 

His Excellency, Ma Lin-yi 

Bishop F. L. Norris 

Dr. Jacob Gould Schurmann 

Dr. George E. Vincent 

Mr. Martin A. Ryerson 

Dr. R. M. Pearce 

Dr. Frank Padelford (vice Dr. E. D. 
Burton, ill) 

Sir William Brunyate 

Dr. J. Christie Reid 

Sir William J. Smyly 

Dr. A. B. Macallum 

Dr. Theodore Tuffier 

Dr. A. de Waart 

Dr. Florence R. Sabin 

Dr. George E. de Schweinitz 

Dr. A. J. Bowen 

Dr. T. H. Lee 

Dr. Mary Emma Woolley 

Dr. Edwin R. Wheeler 

Dr. F. F. Simpson 

Dr. W. B. Nance 

Mr. H. B. Graybill 

Mr. E. C. Jones 

Dr. John G. Clark 

Dr. F. J. White 

Dr. P. M. Roxby 

Dr. William Fletcher Russell 

His Excellency, The Minister for Nor- 
Cuba way 

Brazil His Excellency, The Minister for Den- 
mark 

His Excellency, The Minister for Mex- 
ico 

Bishop L. H. Roots 

Dr. Antonio Sison 

Miss M. K. Eggleston 

Dr. Kenelm Digby 

Dr. Wu Lien Teh 
the Peking Union Medical College 



24 




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OFFICIAL DELEGATES OF EDUCATIONAL 
AND SCIENTIFIC BODIES 

Many organizations sent formal written greetings which were 
placed on exhibition in the buildings of the College. Only institutions 
which gave notification of the appointment of delegates are included 
in the following list. 

American Medical Association 

Dr. George E. de Schweinitz, President 
American Presbyterian Board of Foreign Missions 

Mr. T. H. P. Sailer 
Batavia Medical School 

Dr. A. de Waart, Director 
Bureau of Science, Manila 

Dr. Frank G. Haughwout, Director 
Canton Christian College 

Professor H. B. Graybill 
Canton Hospital 

Dr. W. Graham Reynolds, Chairman of the Board of Directors 
Chinese Eastern Railway 

Dr. P. Lostchiloff, Chief Surgeon 

Dr. G. Tchaplik, Sanitary Division 
Columbia University 

Professor Paul Monroe 
Fuh Tan University 

Dr. Teng-Hua Lee, President 
Fukien Christian College 

Mr. E. C. Jones, President 
Government of the Philippine Islands 

Dr. Antonio Sison, Professor of Medicine, University of the Philippines 
Ginling College 

Mrs. Lawrence Thurston, President 
Hangchow Christian College 

Dr. Warren Stuart, President 
Harvard University Medical School 

Dr. Francis W. Peabody 
Hongkong Medical Association 

Dr. C. C. Wang, President 
Hongkong University 

Sir William Brunyate, Vice Chancellor 

Dr. Kenelm Digby, Dean of the College of Medicine 
Hunan-Yale Medical School 

Professor Brownell Gage, Dean of the College of Arts 

Dr. Edward H. Hume, Dean of the College of Medicine 

2 5 



26 PEKING UNION MEDICAL COLLEGE 

International Health Board 

Dr. Victor G. Heiser, Director for the East 
Johns Hopkins Medical School 

Dr. Florence R. Sabin 
Johns Hopkins University 

Dr. William H. Welch, Director of the School of Hygiene and Public 
Health 
Kitasato Institute 

Dr. Sahachiro Hata 
McGill University 

Dr. A. B. Macallum, Professor of Biochemistry 
Mukden Medical College 

Dr. Peder N. Pedersen 

Dr. W. A. Young 
Mt. Holyoke College for Women 

Dr. Mary Emma Woolley, President 
Nankai College 

Mr. Chang Po-Ling, President 
Nanking University 

Dr. A. J. Bowen, President 
National Medical Association of China 

Dr. Wu Lien Teh 

Dr. Way-Sung New, Secretary 
Peking University 

Dr. J. Leighton Stuart, President 
London School of Tropical Medicine 

Dr. Robert T. Leiper 
Shanghai Baptist College 

Dr. F. J. White, President 
Shantung Christian University, Medical School 

Dr. Edwin R. Wheeler, Acting Dean 
Soochow University 

Dr. W. B. Nance, President 
Southeastern University 

Dr. Ping-Wen Kuo, President 
St. John's University 

Dr. F. L. Hawks Pott, President 
The Rockefeller Foundation 

Mr. John D. Rockefeller, Jr., Chairman of the Board of Trustees 

Dr. George E. Vincent, President 
Tsinghua College 

Dr. P. C. King, President 
University of Chicago 

Dr. Martin A. Ryerson, Chairman of the Board of Trustees 
University of Iowa 

Dr. William Fletcher Russell, Dean of the College of Education 



PROGRAM AND DELEGATES 27 



University of Michigan Medical School 

Dr. Ida Kahn 
University of Paris and French Academy of Sciences 

Dr. Theodore Tuffier 
University of Pennsylvania 

Dr. John G. Clark 

Dr. George E. de Schweinitz 
West China Union University 

Dr. E. W. Wallace 
Yale University 

Mr. Edwin R. Embree 



MEMBERS OF THE MEDICAL CONFERENCE 

Peking, September 15-22, 1921 



Montreal 

Dr. A. B. Macallum 



ANHWEI 

Anking 

Dr. Harry B. Taylor 
Chaohsien 

Dr. Charles A. Powell 
Cbuchow 

Dr. E. I. Osgood 
Hqfei {Luchowfu) 

Dr. Paul R. Tang 

Dr. Frank Vierling 
Hwaiyuen 

Dr. H. Dabney Kerr 
Wuhu 

Mr. Charles O. Lee 

CHEKIANG 

Huchow 

Dr. Fred P. Manger. 
Ningpo 

Dr. S. H. Loo 

Dr. Harold B. Thomas 
Shaohsing 

Dr. Claude H. Barlow 

Dr. W. C. Sweet 

CHIHLI 

Kaicbow 

Dr. J. H. Brown 
Kalgan 

Dr. Harold Hammett 

Dr. P. S. Shi 

Dr. Woo Wai Yii 
Nankou 

Dr. C. S. Hsu 
Paotingfu 

Dr. Charles Lewis 

Dr. Li 



CANADA 



CHINA 



Peking 



Dr. Maud A. Mackey 
Miss Marie Rustin 
Dr. Wang 

Dr. J. Herman Wylie 
7 

Dr. T. Amano 
Dr. K. A. Baird 
Dr. Clementine Bash 
Dr. H. Bonduel 
Dr. J. A. Bussiere 
Dr. P. Bykoff 
Dr. H. Chambers 
Dr. K. O. Chan 
Dr. K. S. Chang 
Dr. Y. N. Chang 
Dr. S. P. Chen 
Dr. Tai-Ao Chen 
Dr. Z. W. Chue 
Dr. Bessie Coffin 
Dr. Carl F. Coffman 
Dr. J. G. Cormack 
Major S. T. Dockray 
Dr. P. M. Fairburn 
Dr. Wu Jui Fang 
Major Gillett 
Dr. S. G. Kirkby-Gomes 
Dr. Douglas Gray 
Dr. Frances J. Heath 
Dr. Myrtle J. Hinkhouse 
Dr. N. D. Hopkins 
Mr. C. K. Hou 
Dr. H. C. Hou 
Dr. E. T. Hsieh 
Dr. J. H. Ingram 
Dr. S. D. Joffick 
Dr. K. Kamo 
Dr. Matsutaro Kanno 



28 



PROGRAM AND DELEGATES 



29 



Dr. Yamei Kin 

Dr. T. E. Koo 

Dr. P. Kuo 

Dr. T. H. Lee 

Dr. Y. T. Lee 

Dr. Eliza E. Leonard 

Dr. Ethel Leonard 

Dr. George D. Lowry 

Dr. Emma E. Martin 

Dr. F. R. McDonald 

Dr. E. Mercier 

Dr. A. Monestier 

Dr. W. B. Prentice 

Dr. S. Ratkitin 

Dr. Jean Redelsperger 

Dr. Ho San 

Dr. L. K. Sang 

Dr. Lydia L. Schaum 

Dr. Anne V. Scott 

Dr. Arthur Shoemaker 

Dr. Wu Tsen I. B. Sia 

Dr. Spourgitis 

Dr. E. J. Stuckey 

Dr. C. C. Tang 

Dr. Hugh W. Y. Taylor 

Dr. Wu Lien Teh 

(Harbin and Peking) 
Dr. C. Chen Ting 
Dr. Y. Tsching 
Dr. Y. Y. Tsui 
Dr. Susan Waddell 
Dr. M. T. Wang 
Dr. Pao-chen Wang 
Dr. W. T. Watt 
Dr. H. F. Wu 
Dr. P. C. Wu 
Dr. T. C. Yang 
Dr. T. S. Yang 
Dr. L. C. Yen 

and 56 members of the staff of 
the Peking Union Medical Col- 
lege 
Tientsin 

Dr. Paul Bauer 
Dr. J. W. Colbert 
Dr. Woo Chi Fen 
Dr. Pond M. Jee 



Dr. H. Y. King 

Dr. L. Howard King 

Dr. Viola Lantz 

Dr. P. K. Liang 

Dr. E. Licent 

Dr. Iva M. Miller 

Dr. E. C. Peake 

Dr. E. Robin 

Dr. Li-Yuen Tsao 

Dr. T. H. Wang 

Dr. George S. Woodard 

Dr. Marion Yang 
Tun gh si en 

Dr. O. Houghton Love 

Dr. Josephine M.Howard-Smith 
Tungpingfu 

Dr. John Kensall Robson 

FUKIEN 

Amoy 

Dr. Edward J. Strick 
Foochow 

Dr. Jesse E. Gossard 
Hinghwa 

Dr. T. Y. Ling 

HONAN 

Changteh 

Dr. Jean I. Dow 

Dr. Percy C. Leslie 
Chengchow 

Dr. T. S. Sung 
Hwaikingfu 

Dr. W. Robert Reeds 
Kioshan 

Dr. Odd Eckfelt 
Weihwei 

Dr. R. G. Struthers 
Wuan 

Dr. F. F. Carr-Harris 
Yencheng 

Dr. H. C. James 

HUNAN 

Changsha 

Dr. Reginald M. Atwater 
Dr. John H. Foster 



3° 



PEKING UNION MEDICAL COLLEGE 



Dr. George Hadden 
Dr. Edward H. Hume 
Dr. Russell F. Maddern 
Dr. Morris B. Sanders 



Wusih 

Dr. Claude M. Lee 

Dr. Y. L. Sz 
Tangchow 

Dr. Frances Cattell Ancell 



HUPEH 

Hankow 


KWANGTUNG (CANTON) 


Dr. Hu Tsen Chiang 


Canton 


Dr. Takeo Ishikawa 


Dr. Charles C. Selden 




Dr. Chee Iu Ting 


Hanyang 

Dr. Robert F. Francis 


Fatshan 




Dr. Richard P. Hadden 


Wuchang 

Dr. Mary Latimer James 
Dr. Paul Wakefield 


Hongkong 

Dr. Kenelm H. Digby 
Dr. G. E. Thomas 




Dr. C. C. Wang 


KIANGSI 


Kongchuen 


Kiukiang 


Dr. Edward W. Kirk 


Dr. David C. Chang 


Swatow 


Nanchang 


Dr. Marguerite Everham 


Dr. George T. Blydenburgh 


O 


Dr. Ida Kahn 


MANCHURIA 




Changchun 


KIANGSU 


Dr. Robert J. Gordon 


Nanking 


Dr. Margaret E. McNeill 


Dr. J. Y. T. Woo 


Chinchowfu 


Nantungcbow 


Dr. Sarah B. Keers 


Dr. G. L. Hagman 


Dairen 


Shanghai 


Dr. M. Tsurumi 


Dr. Vivia B. Appleton 


Harbin 


Dr. W. C. Dalbey 


Dr. P. Lostchiloff 


Dr. C. J. Davenport 


Dr. G. Tchaplik 


Dr. Edward Foucret 


Hsiuyen 


Dr. Henry Fowler 


Dr. Viggo With 


Dr. J. Henry Gray 


Lioyang 


Dr. J. C. McCracken 


Dr. Isabella Aitkin 


Dr. Way-Sung New 


Mukden 


Dr. W. W. Peter 


Kate Drummond, R. N. 


Dr. A. C. Selmon 


Dr. I. Inaba 


Dr. Bertha Loveland-Selmon 


Dr. W. S. Thacker-Neville 


Dr. Phoebe Stone 


Dr. Peder N. Pedersen 


Dr. A. W. Tucker 


Dr. Ethel L. Starmer 


Dr. Sam Bell Wakefield 


Dr. W. A. Young 


Dr. Clara B. Whitmore 


Port Arthur 


Dr. Sien-Ming Woo 


Dr. P. Kunisawa 


Soochow 


1'aheiho 


Dr. K. H. Li 


Dr. Chia-Swee Lin 



PROGRAM AND DELEGATES 

SHANSI 



3 1 



Fenchow 

Dr. Percy T. Watson 
Pingtingcbow 

Dr. Frederick J. Wampler 
1"aikubsien 

Dr. W. A. Hemingway 
Taiyuen 

Dr. Marjorie F. Edwards 

Dr. E. H. Edwards 

SHANTUNG 

Chef 00 

Dr. R. W. Dunlap 

Dr. William Malcolm 
Hwanhsien 

Dr. Chii Pao Ch'in 
Ichowju 

Dr. Emma E. Fleming 

Dr. Benjamin M. Harding 
Laichowfu 

Dr. Jacob McF. Gaston 
Lintsing 

Dr. Paul V. Helliwell 

Dr. Alma L. Cooke 
Pingtu 

Dr. George M. Herring 
I'aianfu 

Dr. Waldo R. Oechsli 



T'ehchow 

Dr. Lois Pendleton 

Dr. Emma Boose Tucker 

Dr. Francis F. Tucker 
1"sinan 

Dr. Samuel Cochran 

Dr. J. Stanley Ellis 

Dr. Philip S. Evans, Jr. 

Dr. P. C. Kiang 

Dr. T. C. Pa 

Dr. Sawasaki 

Dr. Thornton Stearns 

Dr. E. B. Struthers 

Dr. S. P. Tien 

Dr. Edwin R. Wheeler 
1'singtao 

Dr. M. Suzuki 
Weihsien 

Dr. E. W. Ewers 
Tihsien 

Dr. W. R. Cunningham 



Sianfu 



Dr. Alec A. Lees 



SZECHUAN 



Chengtu 

Dr. Arnold Silcock 
The Rev. Edward Wilson Wal- 
lace, B.D. 



Hastings 

Dr. J. Auriol Armitage 



ENGLAND 

London 



Dr. Thomas Cochrane 
Dr. Robert T. Leiper 



Tainan 



Dr. James L. Maxwell 



Paris 



Dr. Theodore Turner 



FORMOSA 



FRANCE 



IRELAND 



Dublin 



Sir William J. Smyly, M.D. 



3 2 



PEKING UNION MEDICAL COLLEGE 



Tokyo 



Dr. Kingo Goto 
Dr. Sahachiro Hata 
Dr. M. Inouye 



Bat a via 



JAPAN 



JAVA 



Dr. Mataro Nagayo 
Dr. Takeo Tamiya 



Dr. A. de Waart 



KOREA (CHOSEN) 



Chinju 

Dr. Charles I. McLaren 
Seoul (Keijo) 

Dr. O. R. Avison 

Dr. K. Shiga 

Dr. Mary A. Stewart 

Dr. F. M. Stites 



Shunshen {Gensan) 

Dr. P. L. Hill, Jr. 

Dr. J. B. Ross 
Songdo 

Carrie Turner, R. N. 
Oriental Consolidated Mines Hospital 

Dr. E. L. Power 



UNITED STATES 



Baltimore 

Dr. Florence R. Sabin 
Dr. William H. Welch 

Boston 

Dr. Francis W. Peabody 

Chicago 

Dr. R. B. Seem 

Manila, Philippine Islands 

Major J. E. Ash, M. D. 
Dr. Frank G. Haughwout 
Dr. Antonia Guillermo Sison 
Governor General Leonard 
Wood, M. D. 



New York 


City 


Dr. 


S. S. Goldwater 


Dr. 


Victor G. Heiser 


Dr. 


Richard M. Pearce 


Philadelph 


ia 


Dr. 


John G. Clark 


Dr. 


George E. de Schweinitz 


Pittsburgh 




Dr. 


Hugh W. Bell 


Dr. 


F. F. Simpson 



117 other persons, from China and abroad, attended sessions of the 
Conference. 



CREDENTIALS OF DELEGATES AND MESSAGES 
OF FELICITATION 

[the president and fellows of harvard college to the fac- 
ulty AND TRUSTEES OF THE PEKING UNION MEDICAL COLLEGE] 

Greeting: 

Harvard University sends its congratulations to the Peking Union 
Medical College upon the Dedication of its Building, at Peking, 
China. 

Gladly availing themselves of the invitation to be represented at 
the ceremonies and at the Medical Conference, September fifteenth 
to twenty-second, nineteen hundred and twenty-one, the President 
and Fellows of Harvard College have appointed Francis Weld 
Peabody, A.B., M.D., Associate Professor of Medicine, as their 
delegate and have charged him to convey their felicitations. 

Given at Cambridge on the twenty-third day of June, in the year 
of Our Lord the nineteen hundred and twenty-first, and of Harvard 
College the two hundred and eighty-fifth. 

(Signed) A. Lawrence Lowell 

President 
(Seal) 

[university of Pennsylvania] 

June 2nd, 1921 
These Letters 

are to designate and appoint our loyal alumnus 

George Edmund de Schweinitz, A.M., M.D., LL.D., 

Professor of Opthalmology 

as our official delegate to represent 

THE UNIVERSITY OF PENNSYLVANIA 

at the dedication of the Building of the 

PEKING UNION MEDICAL COLLEGE 

and at the Medical Conference to be held in Peking, China, from 

September the fifteenth to the twenty-second, nineteen hundred and 

4 33 



34 PEKING UNION MEDICAL COLLEGE 

twenty-one, and to convey through him in person the felicitations 
and high regards of this University to the Faculty and Trustees of 
the College. 

(Signed) Josiah H. Penniman 

Acting Provost 
(Signed) E. W. Mumford 

Secretary 
(Seal) 

[american medical association to the director and trustees 
of the peking union medical college] 

Greeting: 

The Board of Trustees of the American Medical Association has 
designated the President-Elect of the Association, Dr. George E. de 
Schweinitz of Philadelphia, State of Pennsylvania, United States of 
America, to convey to the Director and Trustees of the Peking 
Union Medical College the congratulations and salutations of the 
American Medical Association on the occasion of the dedication of 
the new buildings of the Peking Union Medical College and the in- 
auguration of its new Director, Dr. Henry S. Houghton. 

Issued under the seal of the Association at the office of the Secretary in the 
City of Chicago, Illinois, U. S. A., this twelfth day of July, A.D. 1921. 

(Signed) Hubert Work 

President 
Attest 
(Signed) Alex. R. Craig 
(Seal) Secretary 

[university of iowa] 

The University of Iowa extends its sincere felicitations to the 
Faculty and Trustees of The Peking Union Medical College of 
China upon the dedication of the new hospital and laboratory build- 
ings and upon the inauguration of Doctor Henry Spencer Houghton 
as new director September fifteenth nineteen twenty-one bespeaking 
for that most illustrious institution a continuance of the very hu- 
mane and patriotic service which has characterized it in the past and 



PROGRAM AND DELEGATES 35 

has so distinctly honored in a foreign land the zeal and scholarship 
of this country and in testimony thereof the University delegates as 
its representative at these ceremonies William Fletcher Russell, the 
Dean of its College of Education. 

(Signed) W. A. Jessup 

President 
(Seal) 

[canton hospital] 

To the Peking Union Medical College and Hospital 
Greeting: — 

The Canton Hospital, the oldest in China, hereby extends its 
cordial congratulations upon this auspicious occasion, with earnest 
wishes for the fullest future success in the relief of multitudes, and 
the extension of the compassionate art of medical science. 

(Signed) W. Graham Reynolds 

Chairman, Board of Directors 
Canton, September i, 1921. 
To Dr. Henry S. Houghton, Ph.B., M.D., Director, 

The Rockefeller Foundation, China Medical Board. 
Introducing Dr. Chee Iu Ting, Alumnus, 
Representative of the Canton Hospital. 

[cablegram] 

Washington, D. C. 

To the Peking Union Medical College, Peking. 

Hearty congratulations at the formal opening of your hospital. 

Philip Sze 

[cablegram] 

Washington, D. C. 

To the Peking Union Medical College, Peking. 

I congratulate you upon completion new building, destined to be 
center medical training and research Far East. China at present 
suffers most from lack trained men lead nation safely through period 
transition. To this cause may attributed much of present unrest. It 
is gratifying note that Rockefeller Foundation recognizes China's 



36 PEKING UNION MEDICAL COLLEGE 

pressing need and undertakes give China's young men the best 
training. I take this opportunity offer Foundation best wishes for 
successful work in China. 

Alfred Sze 

[cablegram] 

London 
To Greene, Rockfound, Peking. 

Hearty congratulations good wishes opening ceremony. 

Balme 
moorshead 

[telegram] 

Shanghai 
To Roger Greene, Rockfound, Peking. 

National Medical Association congratulate China Medical Board 
Rockefeller Foundation on completion of new Union Medical Col- 
lege Hospital buildings, and send greetings to all eminent scientists 
and others present at formal opening. 

[telegram] 

Dairen, Manchuria 
To Greene, Medical, Peking. 

On occasion dedication building Union Medical College, I on be- 
half South Manchuria Railway Company take pleasure tendering 
you heartiest congratulation. It will stand out forever as one of 
grandest institutions in Far East for mitigating human suffering. 
No word suffices to express my profoundest appreciation and ad- 
miration of the spirit of Good Samaritan manifested in concrete 
form. Please convey my congratulation also to Mr. and Mrs. Rocke- 
feller. 

President Hayakawa 
South Manchuria Railway Company 

Messieurs: 

L'Academie de Medecine de Paris, qui est la plus haute associa- 
tion medicale francaise, m'a charge officiellement, de vous adresser 



PROGRAM AND DELEGATES 37 

ses felicitations, il en est de raerae de l'Universite de France. Je viens 
done vous demander de me faire dire ou et quand je pourrai m'ac- 
quitter de cette mission envers la Rockefeller Foundation et envers 
vous-memes. 

Veuillez agreer, Monsieurs, l'expression des mes sentiments les 
plus distingues. 

(Signed) Tuffier 



DEDICATION CEREMONIES 



INVOCATION 
By 

The Rev. J. Leighton Stuart, D.D. 

Creating and Controlling Spirit of the Universe, revealing itself in 
the beauty and wonder of this visible world, in the heart and con- 
science of man, and in that One who more than all others has dis- 
closed Thy constant presence, Thy purpose for us, Thy pity for all in 
need of help and healing, and Thy power, we are gathered here this 
afternoon to dedicate this institution to the search for Thy truth 
which relieves human pain and removes human disease — an insti- 
tution which, the buildings and the preparations now completed, be- 
gins its full activities. We invoke Thy blessing upon it. And because 
we believe that all the finer urgings of the human spirit, all the at- 
tainments of science and skill, are from Thee, therefore we thank 
Thee for all that these buildings, their equipment, their staff, their 
program, signify; for the ever-widening knowledge and understand- 
ing of those processes which make for human welfare; for the en- 
larging conception of brotherhood and of ministry to those in need; 
and for the gift making this possible, which has been so generous and 
notable in its conception. Because of the time and energy which 
have entered into all that concerns the great task it undertakes, 
therefore we ask Thy blessing upon it, upon all those who work here 
as they investigate and teach and plan all forms of enterprise and 
activity that make for health and happiness among the people of 
this nation, that they may extend knowledge and truth and hope, 
and that those who study here may go forth much benefited and en- 
lightened, prepared for a larger usefulness; that they may catch the 
spirit of those who have made this possible — the spirit of service 
for others, of sacrifice for their fellows, of devotion to the highest 
ideals of the age, and of loving, devoted activity. Beginning with 
this day and through all its future career may it be guided and con- 
trolled by Thy spirit. We ask in the name of Him who more than all 
others has taught us that knowledge and power lie in concentrated 
effort for the welfare of our fellow-men. Amen. 

41 



PRESENTATION OF THE HOSPITAL AND MEDICAL 
SCHOOL ON BEHALF OF THE ROCKEFELLER 

FOUNDATION 

By 

George E. Vincent, Ph.D., President 

The buildings which are formally opened today have been con- 
structed and equipped by the Rockefeller Foundation through the 
China Medical Board. For the present they will remain the property 
of the Foundation, which puts them at the service of the Peking 
Union Medical College. On behalf of the Foundation I have the honor 
to welcome the Trustees and Staff of the College to laboratories, lec- 
ture-rooms, and hospital. Dr. Henry S. Houghton, the Director of 
the College, will now assume official control and preside over these 
opening exercises. 



42 



ACCEPTANCE ON BEHALF OF THE COLLEGE 

By 

Henry S. Houghton, M.D., Director 

Mr. President: 

On behalf of the College I gratefully accept the use of this great 
gift, with the humble hope that we may make it dynamic with in- 
tellectual and spiritual growth. 
Honored Guests, Ladies, and Gentlemen: 

It is my high privilege, on behalf of the College and its faculty, to 
welcome you to the ceremonies which mark its dedication to service. 
Many of you have come long distances to express by your presence 
here an interest in the work for which the College stands and to bear 
to us the felicitations of other institutions. We are deeply apprecia- 
tive of this good-will and hopeful that it may prove a happy forecast 
of future helpful associations. I record with pleasure the greetings 
brought from many organizations in this and other lands by eminent 
delegates. The full list of these is in your hands. 

In taking up the responsibilities and obligations which this new 
and beautiful setting opens to us, the faculty is not unmindful of the 
broad foundations laid by other hands, and of the devoted service 
given by those who first organized the Union Medical College. 
The ardor and unselfish enthusiasm of these men, some of whom 
laid down their lives in the line of duty, we may well emulate. 

We realize also that the ceremony which dedicates these buildings 
is one in which the men and women to whom their use is committed 
should pledge themselves to the fulfilment of the purposes which 
the founders have had in mind. The primary function of this institu- 
tion is to teach; to do so worthily implies high qualities not alone of 
professional training and experience but of scientific zeal and inspi- 
rational capacity. No motto for the teacher seems to be more apt 
than that suggested in the words of the Twenty-third Psalm, "My 
cup runneth over." The overflowing of impelling personality into 
the lives of others, the constant stimulus to intellectual acquisitive- 
ness, comradeship in work — • these are indices of success in a task 

43 



44 PEKING UNION MEDICAL COLLEGE 

like this. A share in the promotion among our students of high ideals 
for service in the community and state, and of a thirst for righteous- 
ness, adds an obligation of which we are humbly sensible. 

The program of the College includes, we hope, factors significant 
beyond the routine of teaching and research. In the enterprise are 
enlisted men and women of varied nationalities with a common 
interest in the educational problem. This fellowship of different 
nationalities in scientific fields may serve as a small example of in- 
ternational amity in the united effort for the peace and betterment 
of all peoples. 



GREETINGS ON BEHALF OF THE PRESIDENT OF THE 
REPUBLIC OF CHINA 

Presented By 
His Excellency, W. W. Yen 

On behalf of the President of the Republic of China and of the 
Chinese Government I have the honor to extend to you today very 
hearty congratulations and sincere wishes for the success and pros- 
perity of the institution. It is perhaps only once in a lifetime that 
one has the privilege of attending the dedication ceremony of so im- 
portant an institution as this, — an institution the full meaning and 
true worth of which is not to be measured merely by the mag- 
nificence of its buildings, by the wealth and perfection of its equip- 
ment, or by the number and quality of its professors and officers. 
Certainly at no other time in our history has a ceremony like this 
brought together from Europe, America, Japan, and every part of 
China, so large a number of distinguished visitors, celebrated scien- 
tists, eminent educators, and notable religious leaders. Peking, 
therefore, the capital of China, feels very much flattered and hon- 
ored. 

A distinguished fellow-countryman of mine recently made a tour 
of the world, and on his return was asked what had impressed him 
most during his visit to Europe and America. He replied without 
hesitation, "The application of science to every human activity." 
He is entirely right, for the greatness of modern Europe and America 
is due largely to the triumph of science. The employment of scien- 
tific methods in the intellectual and physical worlds has not only 
transformed and ameliorated every phase of human life in the Occi- 
dent, but has also added breadth and brilliancy to its intellectual 
history. The progress made in medicine and surgery in particular is 
phenomenal, and, what is better, the discoveries are here utilized 
entirely and directly for the relief of physical pain and peril. 

The world, and especially China, needs modern science, and yet 
not exactly of the kind that has devastated fertile and smiling 
valleys, that has maimed and killed millions of men in the bloom of 

45 



46 PEKING UNION MEDICAL COLLEGE 

life, and has made widows and orphans in millions of homes, such as 
we have unfortunately witnessed during the late war. Rather we 
welcome in our land, where physical suffering is intense and univer- 
sal, where ignorance of hygiene and sanitation leads to fearful mor- 
tality among the children, and shortens the duration of life among 
grown-up men and women, we welcome, I say, first and foremost, 
modern medicine and surgery, that branch of science which has for 
its motto the love of service, and which distinguishes itself above all 
others by its devotion to the teachings of the Great Healer. 

Unaccustomed to scientific thought, China has been slow in 
adopting Western medicine and surgery, but I sincerely believe that 
with such a magnificent seat of medical learning established in the 
very precincts of our capital, the time will soon arrive when a truer 
understanding and better appreciation will dawn upon the masses, so 
that they will not hesitate to trust themselves entirely to scientific 
treatment. 

In dwelling today on the magnificence of the present institution, 
let us also recall for a moment the memory of the men, who in their 
humble and modest but brave and noble way, laid the first founda- 
tions. The difficulties with which they had to contend in those days 
were such as would have discouraged and deterred men with less 
than apostolic faith and devotion. Nor should it be forgotten that 
the work was taken up and maintained with courage and steadfast- 
ness by a long line of missionaries and professional men, to whom we 
owe a debt difficult to repay, until the whole work is now taken over 
by the Rockefeller Foundation with a munificence that is surely un- 
equalled. 

The President has watched with interest and sympathy the 
growth and final completion of this Medical College and Hospital. 
He has charged me today on behalf of himself and of the Chinese 
Government to thank you, Mr. Rockefeller, your revered father, 
and the Trustees of the Foundation, for this great and splendid phil- 
anthropic act, an act that the present and future generations of 
China will ever regard with pride and affection. May the College and 
Hospital have all the success they deserve, and may they carry on 
their humane work of teaching and healing with ever-increasing 
magnitude and usefulness. 



GREETINGS ON BEHALF OF THE MINISTRY OF THE 

INTERIOR 

By 

His Excellency, Chi Yao-san 

I deem it a great honor to be able to be present at the formal 
opening of the Peking Union Medical College on September 19, in 
the tenth year of the Republic. 

The promotion of education is the first step in the progress of the 
civilization of a nation, and the preservation of the people's health 
is an important function of philanthropic work. In the medieval age 
of China there were special functionaries who had charge of such 
duties, both in the Han dynasty and in the Sung dynasty. In the 
twentieth century, when much progress is being made in the mate- 
rial and spiritual worlds, the increase in the people's welfare depends 
upon the co-operation of the community. 

The building of the Peking Union Medical College in China is of 
great benefit to the country, and the people of Peking entertain 
great hopes of its usefulness in the preservation of public health. 

Upon the inauguration of your new work, which promises to pro- 
duce many competent men, who will bring blessings to many, we 
feel very grateful for your enthusiasm and philanthropic spirit, which 
will strengthen the cordial friendship existing between China and 
America. I wish to exclaim with utmost sincerity: 

Long live the Republics of China and of the United States of 
America! 

Long live the Peking Union Medical College ! 



47 



GREETINGS ON BEHALF OF THE MINISTRY OF THE 

INTERIOR 

By 

S. P. Chen, M.D. 

Mr. President, Trustees of the Rockefeller Foundation, Faculty of 
the Peking Union Medical College, Ladies, and Gentlemen: 

On this auspicious occasion it would not, I think, be inappro- 
priate to say a few words on the progress of Western or modern 
medicine in this country, although it might seem to be a waste of 
your time to listen to any talk on this subject when we are actually 
gathered together to celebrate the opening of this institution which 
is a monument to the progress of modern medical science in China. 

The birth of Western medicine might be taken as dating back to 
the time when lay missionaries, in the course of their work, found 
opportunities for the application of Western medical science. This 
was followed by the advent of the medical missionary and the es- 
tablishment of dispensaries and hospitals. To carry on their work 
satisfactorily the medical missionaries were compelled to undertake 
the training of hospital assistants, and, as time went on, further de- 
velopment along these lines resulted in the founding of medical 
schools. 

Modern medical schools in this country are innovations of this 
century; the earliest Chinese institution was one established in 
Tientsin, and the first foreign school was the one now replaced by 
the magnificent institution we are in. The new Peking Union Medi- 
cal College is but an outward and visible sign of the progress of mod- 
ern medicine in China. Other outward signs are seen in such actions 
of the authorities as the calling out of modern trained men to cope 
with serious epidemics of any kind, the increase in the number of 
medical institutions all over the country, the legalization of dissec- 
tion, and so on. 

There are, however, still other indications of progress known per- 
haps only to those who are in the profession. Personally, I cannot 
claim to speak from ripe experience, but ten years of practice in this 



DEDICATION CEREMONIES 



49 



country would give one a fair idea of the nature of the changes tak- 
ing place. I refer to the gradual change in attitude on the part of the 
general public towards modern medical science. Medical men who 
are connected with hospitals know that the number of people seek- 
ing treatment increases as time goes on. This, I admit, does not 
mean that the general Chinese public places such implicit confidence 
in modern medicine that the day of the quack is past — far from it 
— but when the question is viewed from all sides, it becomes evi- 
dent that Western medicine is steadily gaining the upper hand. It is 
true that modern medicine is often appealed to as a last resort, 
sometimes even when no earthly help is possible. One comes across 
instances when the relatives, upon being asked the actual condition 
of the patient for whom they are seeking assistance, reply in a doubt- 
ful manner that the patient "hai yu i tien-rh ch'i" (is still breath- 
ing), or when they frankly admit that they have tried every other 
"fa tzu" (remedy); it is true that the greater number of cases for 
major surgery will still refuse operation, and that, on the whole, 
there still exists the dread of the knife. But, in spite of all these ob- 
stacles, modern medicine and surgery are slowly but surely replacing 
the older methods. 

Progress for the next few years will necessarily be slow, and its 
rate will be materially influenced by the standard of medical educa- 
tion in this country. I was once informed by one of the officers of 
this institution that the policy of the Peking Union Medical College 
was to turn out quality, and not quantity, and that if it had only 
one student, that student was to be a sound one. If other teaching 
institutions in this country would view the education question from 
the same standpoint, I feel sure the onward march of modern medi- 
cine would be rapid. At present the large number of graduates turned 
out each year by certain of the medical schools serves only one pur- 
pose, and that is to bring discredit to modern medicine, and, in this 
way, to retard its progress. However, with the appearance of better 
manned and better equipped schools for teachers and the output of 
a higher grade product, the whole question will be automatically 
settled by the survival of the fittest. Official recognition of this fact 
would no doubt serve to advance the cause of modern medical 
science, and this recognition would best be shown by the placing of 



So PEKING UNION MEDICAL COLLEGE 

medical education in general, and such questions as the licensing and 
control of medical practitioners in particular, under the independent 
care of a body of medical men of recognized standing. There will 
then be no need whatsoever to interfere with the old time physicians, 
as they must eventually die out. For, in the course of actual prac- 
tice, there will be many opportunities, when the quack has got to 
the end of his tether, for asserting the superiority of modern medical 
science over the more antiquated methods; and, with an increasing 
number of properly trained men who are reasonably sure of their 
ground, such opportunities can be taken advantage of, and the more 
they are encountered the quicker will be the progress of modern 
medicine. 

We look to such institutions as the one whose inauguration we are 
here to celebrate to produce such men, and, in this way, to assist in 
advancing the cause of modern medical science in this country. I am 
therefore happy and proud to be able to have this opportunity of 
wishing the Peking Union Medical College every success in its great 
work. 



GREETINGS ON BEHALF OF THE MINISTRY OF 

EDUCATION 

By 

His Excellency, Ma Lin-yi 

I am glad to see the progress which has been made by the Union 
Medical College in Peking. In recognition of those who have 
helped to make this college such a large and prosperous institution, 
I must express my sincere thanks to the Rockefeller Foundation and 
to the American educators and scientists who are working here. 
And because today is the day for celebrating the completion of the 
new buildings, it is a great pleasure for me to be present. 

In regard to medical science: It is needless to say that much 
progress has been made in Western nations, and that when it was 
introduced into China it caused great surprise because of its new- 
methods of treatment. In my opinion there was in olden times no 
difference between the medical theories and practices of the East 
and the West, for in those days there were similar methods of de- 
termining the cause of a disease and attempting to find a cure for it. 
But later Chinese medical study became more philosophical, while 
Western medicine followed the progress of modern science. Thus the 
systems have come to differ, and, although Chinese medical study 
has a long history and a profound philosophy, we deem it indispen- 
sable to adopt the scientific spirit and the scientific method of West- 
ern medical education. We hope that this college, using both Chinese 
philosophy and Western science may be able to discover new the- 
ories and make great contributions to medical history. 

Because I am acting as Minister of Education and because I take 
a great interest in the promotion of medical science, I will give my 
hearty support to this college, and I hope it will not only render 
good service to China, but also make valuable contributions to the 
world. 



5 1 



RESPONSE FOR THE CHINA MEDICAL BOARD 

By 

Roger S. Greene 

Mr. Chairman, Your Excellencies, Ladies, and Gentlemen: 

It is my special privilege on behalf of the China Medical Board of 
the Rockefeller Foundation to thank the representatives of the 
Chinese Government for their kind greetings and for their good 
wishes for the success of our enterprise. We shall do our best to 
merit the confidence that they have expressed. 

It is not my part, in the presence of so many distinguished scien- 
tists, to discuss the educational policies which should govern this 
youthful institution. I should like, however, to take this opportunity 
to speak of some of the hopes which I cherish for the future of this 
school as one of many agencies tending to promote better under- 
standing between nations. 

The Peking Union Medical College happily seems to possess in its 
organization and location not a few advantages which should help 
to qualify it to play such a part. Beginning as a united effort of Brit- 
ish and American missionary societies, its international character 
has fortunately been preserved in the new organization of its board 
of control. In the faculty and administrative staff, its international 
quality is still more marked. Besides Americans, British, and Cana- 
dians, and some from the continent of Europe, we have the partici- 
pation of a large and growing number of Chinese in all branches of 
the work, and, as time goes on, within the limits imposed by the 
necessity of using a single language as the teaching medium, I hope 
that representatives from other nations may join our forces. With 
the supply of good medical teachers lagging so far behind the de- 
mand, the advantage of being able to ignore national lines in the 
selection of the staff are obvious, and the possibilities of intellectual 
stimulus from the mingling of men with different types of training 
are great. 

But the point on which I should like to dwell for a moment is the 
value of the international character of the organization as another 

5 2 



DEDICATION CEREMONIES 53 

demonstration of the possibilities of co-operation between nations 
when all are working for common and practical ends, so important, 
so absorbing, that they overshadow petty national differences. We 
had such a demonstration in the great war. Here in China we have 
lately seen in the concerted efforts made to relieve the famine, an 
example of how men of different nations have been able to work to- 
gether in an effective and friendly way. Let us remember the im- 
portant work of such an inconspicuous organization as the Interna- 
tional Postal Union. We have lately attempted a union of national 
Red Cross societies, and the moment seems almost ripe for an in- 
ternational health service that shall collect and disseminate informa- 
tion, and be prepared to offer its assistance in times of emergency to 
those nations who are members. Men accustomed, as the staff of 
this College will be, to co-operating with people of other nationali- 
ties in countries other than their own, should be specially qualified 
for such international service and should therefore help to furnish 
one of the elements necessary for its success. International co-op- 
eration in political affairs seems to be attended by endless difficulties, 
but as we acquire a better understanding of one another by working 
together in international trade, in communications, education, 
scientific research, public health, and other normal human activities, 
the final step to some form of political organization that shall safe- 
guard the peace of the world may prove less difficult and less revolu- 
tionary than it has hitherto appeared. 

We hope that this school may help in particular to create a better 
understanding between China and the countries of the West which 
we represent. It comes not only to give but also to receive, for 
probably many of its teachers would not be here unless they hoped 
to learn perhaps more than they can expect to teach; and this is 
well, for the more success they have in preserving the attitude of the 
student in their own work, the better will they succeed as teachers. 
This school is so situated that its workers may not only hope to 
learn much from their studies in China, but they may also profit by 
closer association with the important Japanese scientific institutions 
than is feasible for our scientists at home. The proper development 
of such relations may do much to lessen in this school the feeling of 
isolation which so often depresses scientific workers in a new field. 



54 PEKING UNION MEDICAL COLLEGE 

While we hope that our efforts will result in bettering the condi- 
tion of the Chinese people, it is certain that if we succeed in attain- 
ing that object, we ourselves and all other nations having dealings 
with this great country will likewise benefit; for modern transporta- 
tion has so intertwined the interests of all parts of the world that 
each nation is bound to gain eventually in some degree from the 
increased strength and prosperity of the others. 

I fear that these remarks savor of the platitudes common on such 
occasions as this, and often uttered even by those who are doubtful 
of the truth of what they assert. Unless my proposition is correct, 
however, as I am confident that it is, I see little hope for the perma- 
nent maintenance of friendly relations between East and West. 
Here we have two great groups of peoples, on opposite sides of the 
Pacific, one group living in comparative prosperity and the other in 
relative poverty. Whatever may be the moral and spiritual com- 
pensations that accompany this material poverty, and some of them 
are not to be ignored, the fact remains that human beings all over 
the world do strive for security against hunger and cold and for 
material wealth for themselves and their families. The contrast at 
present between East and West in this respect is too great to be a 
permanent condition. Either those who have little or nothing must 
be enabled to improve their condition at home, or they will even- 
tually go to the country of those who have, and in such numbers as 
to cause a violent upheaval in the country which they invade. At 
present there seems to be nothing to prevent such an invasion from 
ultimately taking place, except armed force or the removal of the 
incentive to such mass movements of people from one country to 
another. In the case of China this incentive can probably be re- 
moved only if we help her to become as strong and prosperous as we 
ourselves are. Therefore those Westerners who are working for the 
development of China, whether in industry, transportation, educa- 
tion, or public health may be assured that if they succeed in promot- 
ing the prosperity and happiness of the Chinese people, they will at 
the same time render an inestimable service to their own countries. 

While sudden mass movements of people from one country to 
another are perhaps justly dreaded, it is to be expected, and it is 
probably desirable that there should be an increase in the move- 



DEDICATION CEREMONIES 55 

ment of individuals and their families from one country to another 
in pursuit of those occupations which naturally take men abroad, of 
which perhaps the most important is a mutually advantageous 
commerce in ideas, for there is no doubt that each side has much to 
learn from the other. Some of these individuals and families who 
migrate will remain permanently in the foreign country which they 
visit. The people of America, and to some extent the people of 
Europe, have not been sure as to what should be their attitude to- 
wards such alien elements in their population, even when the differ- 
ence in race has been slight. Where the difference has been great, as 
in the case of Japanese and Chinese in the United States, the com- 
bination of racial prejudice and not unreasonable fear of serious 
economic consequences, has led not only to the apparently necessary 
measures for the economic protection of American labor but also to 
attempts at other kinds of discrimination which seem to many 
Americans both unnecessary and unjust. This inhospitable attitude 
is defended partly on economic and partly on social or biological 
grounds. If it is rightly taken, it may be possible to justify it by 
arguments based on economic and biological facts, ascertained by 
scientific investigation, or it may be possible to prove by the same 
methods that the fears which have led to discriminatory measures 
are unfounded. But the vital facts, certainly in the biological field, 
are still to be discovered. Whatever the results of scientific study of 
the emigration question by anthropologists may be, and even if, 
as seems possible, no final answer can soon be given, the fact that 
the question has been referred for dispassionate investigation to ex- 
perts will put the discussion on a higher and calmer plane, and will 
lessen the danger of hasty action jnduced by prejudice. If the an- 
swer is found we shall have a basis for a permanent settlement, 
permanent because it will be regarded by all reasonable persons as 
just and necessary. If the workers in the anatomical and physiologi- 
cal laboratories of the Peking Union Medical College can throw 
some light on this one question the effort and expense involved in 
the establishment of this school will be many times repaid. 

This world is now discussing disarmament, with eager longing for 
relief, both from the burden of large armies and navies and from the 
fear of wars which such armament tends to precipitate, but with 



S6 PEKING UNION MEDICAL COLLEGE 

grave doubt as to the practicability of the proposal. If we are to 
make real progress towards our ideals of peace between the nations, 
must we not divert to the positive task of creating conditions favor- 
able to peace, at least part of the enormous energies and resources 
which are now devoted to the negative work of military defense? 
One hesitates to place limits on the benefits which might result if 
but a tenth of the time and money given to our military and naval 
establishments were applied to investigation of problems threaten- 
ing the peace of the world, to enterprises tending to foster the co-op- 
erative spirit, and to the proper education of public opinion. Let us 
hope that the Peking Union Medical College may play at least a 
humble part in such a campaign of peace. 



RESPONSE FOR THE ROCKEFELLER FOUNDATION 

By 

John D. Rockefeller, Jr. 

Oliver Wendell Holmes says in his Autocrat of the Breakfast 'Table 
that every individual is a combination of three persons: first, what 
he thinks he is; second, what his friends think he is; third, what he 
really is. 

I am here today representing not three, but four personalities. 
First of all, I have come to China representing my father, who es- 
tablished the Rockefeller Foundation. I am here, secondly, as a 
representative of the Foundation itself, not inappropriately called 
my father's child. Thirdly, I represent the China Medical Board, 
the child of the Foundation, hence the grandchild of my father. And 
lastly, I am here as a Trustee of the reorganized Peking Union Med- 
ical College, the adopted child of the China Medical Board, hence 
my father's great grandchild. It is fortunate for this assembly that 
I am not particularly interested in genealogy, for otherwise I might 
insist on your climbing with me through the numerous branches of 
this family tree. 

Speaking first for my father, and as his representative, may I say 
how much I wish he were with us that he might himself see and re- 
joice in what is here being accomplished, and that you might feel the 
inspiration of his simplicity and greatness of character. But since 
that cannot be, I am happy to be able to read you a cable message 
which has just been received from him: "My highest hopes are cen- 
tered on the Peking Union Medical College which is about to open 
its doors. May all who enter, whether Faculty or Students, be fired 
with the spirit of service and of sacrifice and may the Institution 
become an ever- widening influence for the promotion of the physical, 
mental, and spiritual well-being of the Chinese Nation." 

On behalf of the China Medical Board, Mr. Greene, the Resident 
Director, has already spoken. Therefore, in the few moments at my 
disposal, as a representative of the Rockefeller Foundation, the 
grandparent of the baby, — an adult infant to be sure, — - whose re- 

57 



58 PEKING UNION MEDICAL COLLEGE 

christening we are here today to celebrate, I shall devote myself 
chiefly to the youngest offspring of this family tree, the Peking 
Union Medical College, of whose origin, prenatal history, birth, and 
early development I desire to speak briefly. 

As my father's interest in human betterment widened, and it 
came within his power to render service to his fellow-men beyond the 
boundaries of his own country, his attention was naturally directed 
to the great Chinese Nation, with its history running back thousands 
of years; its early achievements in industry; its literature and art, so 
rich and beautiful; and its population, greater than that of any other 
nation on earth. Feeling that perhaps by seeking to assist in the es- 
tablishment of high educational standards the greatest service could 
be rendered to the Chinese people, my father made possible the 
sending of a commission from the University of Chicago, in the year 
1909, to study the educational conditions of China. The commis- 
sion, composed of Dr. Ernest D. Burton, Professor of Theology, and 
Dr. Thomas C. Chamberlin, Professor of Geology, after thorough 
study, recommended the establishment at Peking of an educational 
institution for the teaching of the natural sciences. However, so 
gigantic seemed the undertaking and so important the avoidance of 
a false step, that further study and conference were deemed desir- 
able before any move was made. This led to the conclusion that to 
focus thought and effort on one group of sciences, namely the medi- 
cal sciences and their application, was the wiser course to follow. 
A second commission was therefore sent to China in 1914, consisting 
of Dr. Harry Pratt Judson, President of the University of Chicago, 
Dr. Francis W. Peabody, of the Medical Faculty of Harvard Uni- 
versity, and Mr. Roger S. Greene, at that time Consul General of 
the United States at Hankow, now Resident Director in China of 
the China Medical Board. This group was requested to study the 
medical needs of China and the opportunities for co-operation in 
meeting them. The commission returned convinced of the wisdom 
of the conclusion already reached and recommending the establish- 
ment of a medical school and hospital at Peking and a similar medi- 
cal center in Shanghai. Before final action was taken, however, a 
third commission went out in 191 5, composed of Dr. William H. 
Welch, of the Johns Hopkins University Medical School, Dr. Simon 



DEDICATION CEREMONIES 59 

Flexner, of The Rockefeller Institute for Medical Research, Dr. 
Wallace Buttrick, Secretary of the General Education Board, and 
Dr. Fred Gates, also of The Rockefeller Institute. The report of 
this commission corroborated the findings of its predecessor and cor- 
dially endorsed the program of establishing the two medical cen- 
ters previously recommended. Going further, it advised entering 
into an alliance with the Peking Union Medical College, which had 
been in operation for several years, and building upon that founda- 
tion the medical school proposed for Peking. 

Let me pause just here to say that in the light of subsequent events 
and experience it became clear that the main objects sought could 
be attained by the development of a medical school in Peking alone. 

In the meantime, the Rockefeller Foundation had established the 
China Medical Board as a subsidiary organization to deal with med- 
ical and health questions in China. The China Medical Board there- 
fore entered into a contract for the purchase of thelandand buildings 
of the Peking Union Medical College and the reorganization of its 
Board of Trustees. The new Board was to consist of thirteen members, 
each of the organizations which had been associated in the founding 
and development of the College to have one representative, namely: 
the Medical Missionary Association of London, the Society for the 
Propagation of the Gospel, the London Missionary Society, the 
Board of Foreign Missions of the Presbyterian Church in the United 
States of America, the Board of Foreign Missions of the Methodist 
Episcopal Church, the American Board of Commissioners for 
Foreign Missions; the seven remaining Trustees to represent the 
China Medical Board. The contract also contained an agreement on 
the part of the China Medical Board to erect the necessary addi- 
tional buildings and provide such maintenance funds as in the 
judgment of the Board might be required until the College should 
become permanently established and its future should be assured. 

The purpose of the China Medical Board in entering into this 
contract was to develop in China a medical school and hospital of a 
standard comparable with that of the leading institutions known to 
Western civilization. In this contract it was proposed to offer to the 
Chinese people facilities for acquiring a thorough knowledge of and 
training in Western scientific medicine. While it was intended that 



6o PEKING UNION MEDICAL COLLEGE 

the college should lay emphasis upon the training of promising men 
and women for positions as teachers and investigators, it was of 
course realized that many of its graduates would enter the service of 
the community as well-equipped physicians and surgeons. It was 
also a part of the plan to provide short courses for medical mission- 
aries and Chinese doctors throughout the Chinese Republic that 
they might be enabled to keep pace with the rapid strides made by 
modern medicine and might be helped to make of the greatest serv- 
ice the many useful medical enterprises which they were carrying 
on. But above all it was hoped that this new medical center might so 
commend itself to the Chinese people that it would stimulate them 
to develop similar institutions in various parts of China. For the 
China Medical Board recognized from the outset that only the 
Chinese Nation itself could cope with a task so colossal as the es- 
tablishment of modern scientific medical education throughout the 
Republic and that all Western civilization could do would be to point 
the way. 

There have been purchased for the Peking Union Medical College 
considerable areas of land and fourteen main buildings. Fifty-five 
residences and auxiliary structures have been built or remodelled, 
all of which are now complete and ready for occupancy. The College 
is now offering to both men and women students the regular medi- 
cal courses with its practice work in dispensary and hospital, and a 
pre-medical course as well. It is also conducting a training school 
for nurses. 

As regards graduate instruction, it is intended that in certain 
subjects, where the need is great, short courses such as are now 
being given to medical missionaries and Chinese practitioners will be 
provided. It is believed, however, that a more valuable service will 
be rendered by affording opportunities for more prolonged and 
thorough training of those suitably qualified by receiving them, in 
necessarily limited numbers, for a period of months or even a year 
as volunteer assistants or special workers in the various departments, 
whereby they become for the time being a part of the organization. 

While the primary function of the College, as of every medical 
school, is educational, opportunities have been provided in its labo- 
ratories and in the Hospital for the prosecution of research in the 



DEDICATION CEREMONIES 61 

fundamental medical sciences and clinical subjects. A medical 
school imbued with the scientific spirit and prepared not only to 
impart but also to advance knowledge is capable of rendering an 
inestimable service to China in the influence which it may exert upon 
the standards and the methods of medical education, in the training 
of teachers and leaders in the profession and in contributing to the 
solution of the many problems of disease in this country. Abundant 
experience has demonstrated that teachers gifted with the inclina- 
tion and capacity for productive investigation are able to combine 
with their duties as teachers the prosecution and the stimulation of 
research and to gather about them advanced students and special 
workers whose contributions extend the reputation of teacher, 
department, and school. 

A grateful service which the College will be glad incidentally to 
render to the community through the Hospital and Dispensary, is 
the alleviation of suffering. But the number thus reached will of 
necessity be relatively small, for it must be borne in mind that the 
Hospital is primarily a teaching institution, which while affording 
the best care for patients, exists, first of all, for instruction and re- 
search. Moreover, while the College has not been established to serve 
the foreign community it will do all that is possible, within the lim- 
its of its primary purpose, to receive serious cases into the hospital, to 
assist private physicians in diagnosis, and to enter into consultations. 
Obviously, however, the medical staff cannot, in justice to its first 
duty of teaching and research, be expected, except in rare and 
critical cases, to make calls upon patients in Peking or to undertake 
journeys to distant points. But we are happy in the belief that other 
hospital facilities now available in Peking and an increasing number 
of well-trained medical men will be able to give adequate care to 
foreign as well as to Chinese patients. 

Toward the realization of the purpose which has animated it from 
the outset, the China Medical Board has spent in developing the 
Peking Union Medical College well nigh twice the sum which the 
present physical plant and equipment would have cost before the 
war. Several factors combined to bring about this result. Just as 
the building program was well under way, the rate of exchange 
doubled, an item alone which increased the cost of the plant by 



62 PEKING UNION MEDICAL COLLEGE 

nearly two millions of dollars gold. Moreover, as a result of the war, 
freight rates rose so rapidly and the delays in shipping were so great 
that very considerable extra cost was thereby involved. Then, too, 
the fact that the China Medical Board had had no previous expe- 
rience in building in the Orient doubtless somewhat increased the 
total outlay. Probably a fair valuation of the physical properties of 
the College today, including the land, would approach five millions 
of dollars gold. 

In drawing plans for the medical buildings and hospital, it has 
been necessary to follow Western design and arrangement in the in- 
terior of the buildings in order to meet the requirements of modern 
scientific medical practice. At the same time we have deliberately 
sought in so far as possible, although at no little additional cost, to 
combine with utility of interior the beauty in line and decoration of 
the Chinese exterior, particularly as regards height, roof structure, 
and ornamentation. 

This we have done in order that the Chinese people for whose use 
these buildings have been constructed may feel at home in them and 
be drawn into closest sympathy and co-operation with the work 
which they house, and also as a sincere expression of our apprecia- 
tion of the best in Chinese architecture. That we have been success- 
ful to some degree in stirring the interest and appreciation of the 
Chinese is evidenced by the following excerpt from an article by Sam 
Dean entitled, "Singing Craftsmen of Peking," which appeared in 
the August (1921) issue of Asia. 

"Master Chinese craftsmen have told me, in expressing their 
opinion of the Rockefeller Hospital at Peking, that no other building 
erected in China in the past century was so profound an inspiration 
to Chinese artisans. They did not like the window-casings, they felt 
the lack of the massive, deep-shadowed effect that columns would 
have produced and they thought the unsupported walls too frail for 
the roof, but, because the building was one in which the soul of a 
people could express itself, they traveled long distances for the 
privilege of working on it, even in the humblest capacity. Men who 
were master stone-carvers in their own districts were willing to 
work as coolies, if only they might say they had been employed in 
the construction of this building. Farmers from the Western Hills, 



DEDICATION CEREMONIES 63 

descendants of the architects that built the Peking palaces, were 
content to haul dirt on wheelbarrows if they too might have some 
share in this masterpiece. I once met an old artist, a painter of tem- 
ples from his boyhood, who had painted certain of the figures near 
the roof of the hospital. From the ground they were barely visible, 
but he had put the training of a lifetime and all his soul into the 
work. 'It is,' he said, 'my monument.'" 

Surely it is not too much to hope that the same fidelity and devo- 
tion to their task which characterized some of the artisans who 
erected those buildings, may be inspired by the buildings in the 
students who use them. 

But we have realized that stone and wood, however cunningly 
and skilfully fashioned, and equipment however complete, cannot 
make a medical school; that this result is dependent upon the qual- 
ity of mind and heart which the faculty brings to bear in its work. 
Hence the United States, Great Britain, Canada, as well as China, 
have been drawn upon in making up our family, which is composed 
of men pre-eminently fitted for their work and entering into it in a 
fine spirit of loyalty and enthusiasm. 

Particularly gratifying is it to be able to bear testimony to the 
excellent work and promising character of a number of the young 
Chinese members of the staff, whose development we are following 
with the greatest satisfaction. 

We have realized, too, that although we might give to the Chinese 
medical students who pass through the College training as good as is 
to be had anywhere, that alone would fall far short of equipping 
them for their life work as the highest type of medical practitioner 
should be equipped. For only as their professional skill goes hand in 
hand with high character, only as they are inspired with the spirit of 
service and of sacrifice referred to in the message from my father, 
will our graduates be of the most value to their fellow-men and to their 
country. And it is because we believe that the highest character is 
built upon the deepest spiritual foundations alone that we have 
sought to bring together a medical faculty not only with the best 
scientific equipment but possessed at the same time of the finest 
idealism. In other words, it is the desire of the Peking Union Med- 
ical College to offer to the people of China the best that is known to 



64 PEKING UNION MEDICAL COLLEGE 

Western civilization not only in medical science but in mental devel- 
opment and spiritual culture. While, therefore, we shall willingly 
minister to the bodily needs of those who come within our doors 
seeking physical aid only; while we shall gladly afford training for 
the minds of those who come for that purpose, and while it is our 
profound conviction that the best in any man can be realized only 
as his nature becomes receptive to the highest spiritual influences, 
at the same time it is not our purpose to force upon any one that 
which he does not wish; nor shall we refrain from serving those who 
come to us for aid along any one of these three lines of human better- 
ment because he does not wish help along all three. 

With the Medical Missionary Boards which have been most zeal- 
ous in the development of medical missions, and with the work 
which they have undertaken, the Peking Union Medical College 
wishes at all times to be in most cordial co-operation. We are here to 
supplement, not to supplant, what they are doing; to aid, not to 
impede, them in their efforts. In fullest sympathy with the mission- 
ary spirit and purpose, we are desirous of furthering it as completely 
as may be consistent with the maintenance of the highest scientific 
standards in the Medical School and the best service in the Hos- 
pital. We would ever show respect for the genuine spiritual aspira- 
tions, evidenced in service and sacrifice, of those who come within 
our doors, whatever their views, — for after all is it not a fact that 
the final test of true religion is the translation of that religion into 
the highest type of life? 

Rome was not built in a day, nor can the ideals which animated 
the founders of the new Peking Union Medical College be realized 
in a day, or a year, or a decade. A mushroom growth is short lived. 
The most stable and enduring structure is that which is built on 
deep and broad foundations. This enterprise was entered upon, as 
has already been pointed out, only after years of careful study and 
deliberation. The purpose of those who are back of it has never 
weakened or changed. The one danger to be carefully avoided is the 
temptation to too rapid growth and a superficial development. 
Gradual growth alone gives assurance of stability and permanence. 
A frank recognition of this danger at the outset and concerted action 
on the part of the trustees and faculty in standing resolutely 



DEDICATION CEREMONIES 6$ 

against it will insure its avoidance. Patience will be needed on the 
part of the faculty, the students, and the public in the development 
of this institution. Certain departments may not be fully organized 
or completely equipped for some time to come and a few may not 
even be started until later. We shall endeavor, however, to maintain 
a high standard for those departments which have been established. 
So long, therefore, as all those related to the enterprise are working 
together in a spirit of sympathetic co-operation toward the attain- 
ment of the ultimate ideals which we have set before us from the 
outset, each step taken will be a step of real progress in reaching the 
final goal. 

In order that one of the foremost objects of the China Medical 
Board in building up the Peking Union Medical College may be at- 
tained, namely, that the College may serve to stimulate the develop- 
ment by the Chinese people of similar institutions, it is essential 
that the current cost of operating should always be kept on a con- 
servative level. If a policy other than this is followed and a school 
set up here more expensive to maintain than comparable institu- 
tions in America and Europe, not only will a disservice have been 
rendered to the cause of medical education and hospital develop- 
ment throughout the world, but the Chinese people will not be so 
ready to undertake the creation and maintenance of similar institu- 
tions in other parts of the Chinese Republic. 

Clearly, whatever Western medical science may have to offer 
China, it will be of little avail to the Chinese people until it is taken 
over by them and becomes a part of the national life. So we must 
look forward to the day when most, if not all, of the positions on the 
Faculty of the Peking Union Medical College will beheld by Chinese; 
when the Board of Trustees, while embracing appointees of those 
bodies which founded the institution, as well as other representa- 
tives of Western civilization in China, will include leading Chinese; 
and when such current support as the institution may need beyond 
that derived from tuition fees and such endowment as may be set 
aside by its founders, shall be derived from Chinese gifts and gov- 
ernmental subsidies, as is the case with medical institutions of sim- 
ilar rank in other countries of the world. Let us then go forward with 
one accord towards the attainment of this objective which will make 



66 PEKING UNION MEDICAL COLLEGE 

permanent the establishment on Chinese soil of the best in scientific 
medicine that the world can offer. 

Recently, when the pneumonic plague appeared in Shansi, the 
Minister of the Interior assigned certain physicians, among them 
Dr. Yu Shu Fen, to combat it. Dr. Yu succumbed to the disease, and 
realizing that he could not recover, dictated a farewell message in 
which this remarkable paragraph occurs: "With my enthusiasm for 
plague prevention I overstepped the bounds of convention and in 
my constant contact with the plague accidentally contracted the 
disease. I am dying for the people. I have no complaint." Just a few 
days before his death Dr. Yu had written in the guest book of Dr. 
F. F. Tucker of Tehchow: "I come to fight the plague and to put 
into practice God's love for men." 

When the Peking Union Medical College faculty is manned with 
Chinese professors of Dr. Yu's type, bringing to bear upon the stu- 
dents of the College the influence of such lives, and when men of 
that caliber are each year being graduated from the college to spread 
abroad throughout this great land the healing of the body and the 
inspiration of the soul of the Chinese people, the spirit of service 
and of sacrifice, in which this institution was conceived, will have 
been immortalized and one of the chief purposes for which the 
college was founded will have been realized. 



ADDRESS AT THE RECEPTION AT THE PRESIDENT'S 

PALACE 

By 

His Excellency, President Hsu Shih-ch'ang 

China and America are far apart, but cordial relations are main- 
tained between us, because both have adopted the same form of 
government and both are striving for universal peace. Americans 
are keenly interested in public welfare and the Chinese also are a 
charitably disposed people. The aims of the two Republics converge 
and their friendship daily grows more intimate. 

It gives me special gratification to have this opportunity of re- 
ceiving this large and distinguished gathering from different parts of 
the world to celebrate the opening ceremonies of the Peking Union 
Medical College. It is indeed a brilliant assembly. One of our phi- 
losophers, writing on Universal Love and Altruism, said that a 
physician is the Minister of Love and Humanity; his virtue dis- 
penses benevolence, his knowledge brings healing. 

The Peking Union Medical College has been established for many 
years and hundreds of students have been trained. Its hospital has 
treated all kinds of diseases and treated many patients with marked 
success. 

The new buildings are solid structures, exquisitely finished, 
combining the best features of Chinese and Western architecture 
and equipped with the most modern appliances. Their completion 
surpasses all past efforts of a similar nature in China. They exem- 
plify the principle of Universal Love and Altruism. They will 
greatly benefit our society and arouse in the hearts of our people a 
broader love, a deeper sympathy, and a higher effort to imitate the 
noble example set before them. Our philosopher's words will then 
be fulfilled and I shall not be alone in feeling gratitude for the bene- 
fits to be derived therefrom. I take this opportunity to thank you, 
Ladies and Gentlemen, for your presence and I wish you every 
success and prosperity. 

67 



EVENING ADDRESSES 



MEDICAL EDUCATION IN CHINA: A SURVEY AND 

FORECAST 

By 

Edward H. Hume, M.D. 

EARLY HISTORY 

In the year 1692 the Emperor K'ang Hsi was seized with a fever 
that threatened his life. The court physician employed every means 
known to Chinese medicine but failed to cure him. Then the Em- 
peror recalled that the Jesuit Fathers, Gerbillon, Bouvet, and de 
Fontenay, had boasted of the virtue of a drug recently brought from 
Europe, quinine, to which the Emperor had himself given the name 
"divine remedy." Failing to be cured by the court doctors, K'ang 
Hsi asked that he be given the European remedy, but the official 
physicians refused to permit this because they considered it too rash 
to experiment with an unknown remedy on an imperial personage. 
Three of the physicians urged that all treatment be deferred until 
the nature of the disease should be more fully investigated. The 
Emperor, however, disregarding their advice took the European 
remedy and on the evening of the same day was without fever. Al- 
though there were slight recurrences during the days that followed, 
the Emperor again insisted on more thorough treatment with the 
Peruvian bark and soon was entirely well. 

Gathered as we are tonight in this capital where the record of im- 
perial days is writ large on every hand, — and coming together as 
the guests of this institution where East and West have so truly met, 
the West coming as a student to the East to be taught in the ways 
of architecture, while bringing to it some knowledge of the common 
problems and needs of mankind's well-being, so that both may join 
hands as they seek to understand and solve them — we do well to 
inquire of the imperial patient. It is easy to imagine him, resting 
beside one of those enchanting lakes just over yonder, bringing to 
mind as his convalescence progresses the story of what China has 
done for medical education. The open lotus blossoms seem to reach 

71 



72 PEKING UNION MEDICAL COLLEGE 

up from the water and beckon him back to the early days. Had not 
Shen Nung, the Father of Medicine, tasted a hundred herbs ? Was it 
possible that he had found anything so bitter as this foreign bark? 
And had not Huang Ti, who followed him, in collaboration with his 
chosen prime minister Ch'i Pei, compiled the Classic of Internal 
Medicine and other books that were to be the means of instruction 
for untold hundreds of years? 

The Emperor turned rapidly from volume to volume, not stopping 
to read again the story of Ho and Huan, the great teachers before 
the time of Christ; or to recall other medical names that had become 
glorious in history. In the Sui dynasty (581 to 618 A.D.) he found 
that medicine had already become departmentalized, that special 
chairs were established, and that pupils were enrolled in each. It 
was during this dynasty that Fuyiwaiyi, a Japanese student of 
medicine, probably the first of those from his nation, came and 
studied in China for fifteen years. Not until he came to the records 
of the Sung dynasty, however, did K'ang Hsi find evidence of true 
medical schools. 

It was while William the Norman was putting in order the Island 
Kingdom where only two years before he had been victorious, 
that Shen Tsung called together the scholars and organized the 
medical teachings of the early masters, giving continuous instruc- 
tion, and arranging for regular examinations. Still later, when the 
Mongols were at the height of their power in China, one of the 
officers from the Great Court of Medicine was entrusted with the 
teaching of selected students and with the responsibility of deter- 
mining by periodical examinations their fitness for public use. 
Grateful that his country had been active from the earliest days, the 
Emperor gave the books back to the attendant and rested once more. 

We, too, must give our measure of honor to these masters of the 
early days, who carried in their hearts the sufferings of their country- 
men and strove to find and supply remedies for their healing. And 
yet (I quote from Dr. Wu Lien Teh), "in spite of some excellent 
methods of treatment and a long list of useful drugs handed down 
by the ancient teachers of medicine, nothing has been done by their 
successors either to improve knowledge or keep abreast of the 
times. The results are deplorable, and the majority of native-trained 



EVENING ADDRESSES 73 

physicians of today are completely ignorant of the true causes of 
most diseases, their methods of diagnosis, and their modes of pre- 
vention." "Instead of dissection," says a teacher writing in the 
Soochow Alumni Medical Journal, "superstitions have prevented 
our examining the body. Our medical teaching is founded on empty 
theory. Instead of picturing the heart as the centre of the circula- 
tory system, we call it 'the prince.' The liver, instead of being de- 
scribed in its relation to metabolism, is said to be ' the commander- 
in-chief.' " Is it any wonder, then, that even as early as the Chou 
dynasty, a thousand years before Christ, officials who knew the in- 
adequacy of medical knowledge, warned the public against swallow- 
ing the medicine of any physician whose family had not been in 
practice for at least three generations? Or that a decree went forth 
requiring that all medicine administered to a ruler of the state must 
first be tasted by the prime minister? Surely it must have proved 
difficult for the Jesuit priests who provided the quinine for K'ang 
Hsi to find favor with his Chief Executive! 

MODERN MEDICAL EDUCATION 

An old Rugby schoolboy, Thomas Richardson Colledge, founded 
the first dispensaries in China; first in Macao in 1827 and the follow- 
ing year in the city of Canton. Joined in 1834 by Peter Parker, a 
Yale graduate, recognized as the first medical missionary in China, 
he soon found that they must train up assistants, and also go to the 
public for support for their medical undertaking. Thus there came in- 
to being the Canton Medical Missionary Society, the first of its kind. 
This Society was formed to encourage Western medicine among the 
Chinese by affording an opportunity for Christian philanthropy and 
service; and to cultivate confidence and friendship, thus introducing 
the Gospel of Christ in place of heathenism. But much more than this, 
it was "to provoke inquiry into truth by opposing exact science to 
superstitious ignorance (It must be remembered that when they 
spoke of exact science no single one of the pathogenic bacteria had 
yet been discovered.) ; to educate Chinese youths in Western medi- 
cine; to advance general medical knowledge by the reflex benefits 
which will accrue from scientific discoveries in China." I doubt 
whether the Trustees of the Peking Union Medical College, even 



74 PEKING UNION MEDICAL COLLEGE 

with the full program of the Canton Society before them, could 
draw up a statement that would more adequately express the objects 
of this institution in which we are assembled. 

It was thus under Parker and Colledge, as early as 1840, and later 
under Kerr of the same hospital, that modern medical teaching be- 
gan. In 1870, medical students were formally admitted and the 
translation of textbooks was taken up in earnest. In 1879, the first 
Chinese women to begin medical studies entered this school. In the 
meantime, however, Benjamin Hobson of the London Missionary 
Society, while practising in Hongkong, in Canton, and later in Shang- 
hai, lectured, taught, and translated continuously. 

Forty years ago the Viceroy, Li Hung Chang, grateful to Dr. 
Mackenzie for saving the life of Lady Li, provided quarters in Tien- 
tsin for the opening of medical school work; gave Dr. Mackenzie the 
funds with which to carry on his classes; imposed no hindrance to 
religious teaching; and thus started the earliest school of medicine 
among those that are still active. During Mackenzie's lifetime nine- 
teen men graduated; but they did not get posts commensurate with 
their training. The school, however, is still in existence and is now 
the Navy Medical College. 

Still another formal experiment was made by Dr. W. W. Myers 
at the David Manson Memorial Hospital in Takow, Formosa. 
Three students were graduated in 1888 but they, too, were unable 
to get suitable posts in this country and settled in the Straits Settle- 
ments. From those days until now men of vision have given personal 
instruction or taken part in the founding of schools. From North to 
South we shall find the evidences of their devotion. They won confi- 
dence for Western medicine and exerted a deep spiritual influence 
and, more than that, they sent out pioneers who through daily 
association with the Chinese, gave them inspiration for service. I 
wish we might count tonight those in this hall who have had valiant 
aid from men thus trained. And that we might pause to give per- 
sonal thanks to the leaders at schools like those at Hankow, Nan- 
king, and Soochow, who, after instilling a love for medical mission- 
ary service into the hearts of men, saw the wisdom of uniting their 
forces with those of other centers. It is nearly a hundred years since 
Colledge started his first dispensary and forty years since Macken- 



EVENING ADDRESSES 75 

zie launched the first modern medical school in China! What is the 
record of their successors today? 

An inquiry made in August, 1921, showed that there were twenty- 
four medical colleges in China. Eleven of these are Chinese institu- 
tions, eleven are under foreign control, and two others are managed 
co-operatively by Chinese and Westerners. Of the Chinese colleges, 
three are supported by as many ministries of the Central Government 
(the Board of Education College, the Army Medical College in 
Peking, and the Navy Medical College in Tientsin); four by Pro- 
vincial Governments (one at Paoting in Chihli, one at Hangchow in 
Chekiang, and two in Kiangsu, the Central Provincial College at 
Soochow, and the former German College now located at Woosung) ; 
and four by private groups, the Nantungchow College and the Dung 
Dai College in Kiangsu; a woman's college at Hangchow in Che- 
kiang; and the Kwong Wah College at Canton. 

Of the foreign-controlled colleges, two receive a measure of gov- 
ernment aid (the Japanese South Manchurian College in Mukden 
and the Hongkong University Medical School under British con- 
trol). This one in Peking, whose guests we are, is under a board of 
thirteen trustees, six representing the six missionary societies orig- 
inally maintaining the Union Medical College and seven represent- 
ing the China Medical Board of the Rockefeller Foundation. The 
remaining eight colleges are conducted by missionary societies. 
Three of the eight are union institutions in which British and Ameri- 
cans co-operate (Tsinan, Foochow, Chengtu); British and Danish 
teachers co-operate at Mukden in another; the Peking Women's 
Union College is an American institution; the British China Mis- 
sionary Society maintains a college in Hangchow, while the other 
two are conducted by American societies — St. John's in Shanghai 
under the Episcopal Board, aided by contributions from the Univer- 
sity of Pennsylvania, and Hackett Medical College at Canton. The 
other two colleges are the Hunan-Yale College of Medicine, con- 
ducted co-operatively by the faculty of Yale-in-China at Changsha 
and a society of Hunanese leaders interested in medical education; 
and the Kung Yee College in Canton, controlled by a Chinese 
board, but under the professional supervision of American teachers. 

A few facts about these colleges should be considered. As regards 



76 PEKING UNION MEDICAL COLLEGE 

their location: twenty-two are in provinces bordering on the sea 
(three in Chekiang, six in Chihli, one in Fukien, five in Kiangsu, four 
in Kwangtung, two in Manchuria, one in Shantung) ; while the other 
two are in Hunan and Szechuan, respectively, far in the interior. 
Grouped according to the language used as the medium of instruc- 
tion: fifteen teach in Chinese, five in English, and one in Japanese; 
while two use both Chinese and German, and one Chinese and French. 
Fifteen of the colleges are at present teaching only men; three are 
exclusively for women; while the remaining six admit both men and 
women students, though in two of the six, women are as yet regis- 
tered only in pre-medical classes. 

It is impossible at the moment to give exact figures as to the total 
number of graduates from these twenty-four colleges. There are 
certainly not over 3,000. Add to this those who were taught pri- 
vately or in colleges that have ceased to function, and we shall get a 
grand total of probably not more than 4,000 or 4,500 as the figure 
representing those who have received a more or less full measure of 
personal or institutional training in Western medicine. The propor- 
tion of these that has had sufficiently thorough preparation and that 
has developed sufficiently sustained ideals to justify the designation 
"fully qualified" is exceedingly low. 

The total number of medical students in China in regular colleges 
is a little over 2,000; of which number only ninety-five are women. 
In addition to this number, the six colleges that require thorough 
pre-medical science courses have between one and two hundred 
students under their immediate supervision. 

The numerical strength of the faculties at the different colleges 
varies from four at Foochow to forty-three at the Peking Union 
Medical College. (It is only fair to state that since this report was 
commenced the Foochow College has decided, on account of the 
shortage of teachers and other factors, not to continue instruction 
for the present.) These numbers are in addition to the faculties of 
the pre-medical schools. 

The variations found in the reports on budgets are extreme. The 
Hangchow Woman's College reports a total budget of $2,500 silver; 
while the total budget of the Peking Union Medical College was 
$800,000 silver last year. These figures include, in practically all 



EVENING ADDRESSES 77 

cases, the total cost for college and hospital. It is difficult to get a 
wholly accurate statement as some teachers volunteer their services, 
and in some of the budgets the salaries of the foreign teachers are 
not included. The two co-operative colleges receive annual grants 
from their respective provinces, Hunan and Kwangtung. The 
Hunan-Yale College is promised an annual subvention of $50,000 
silver (of which amount $41,000 was paid in 1920); and the Kung 
Yee College also receives a regular grant from the Canton Govern- 
ment. In addition to these grants to colleges conducted co-opera- 
tively with the Chinese, the Mukden Medical College receives about 
$6,000 silver from the Provincial Government of Manchuria and 
the Medical School of Shantung Christian University receives an 
annual grant of $5,000 silver, unfortunately reduced lately to $3,000. 
Constant military activity in China during the past few years has 
hindered educational progress in many of the provinces; and yet a 
most determined effort is being made to fulfill these special con- 
tractual obligations, especially where foreign staffs are involved. 

High rates cannot be charged for medical teaching for a long time 
to come, that is, in most parts of China. The Army and the Navy 
Medical Colleges provide free tuition for those who pass the entrance 
examinations; while the fees charged in other colleges range from a 
standard average of $20 silver a year, for tuition only, in the Chinese 
Government institutions, to $300 silver a year at the University of 
Hongkong. Board and room cost from $30 a year up. And even the 
moderate fees at most of the colleges, prevent many an able candi- 
date from registering. Times without number have students come 
to ask for scholarship aid or for suggestions as to self-support even 
though the fee was only $30 per year. Such is the economic border 
line beside which a considerable proportion of students in China 
live. 

How shall we evaluate the colleges that today are attempting to 
carry forward the torch of medical science? What of their resources? 
What of their ideals, their equipment, their teachers, their produc- 
tive research? With few exceptions, they are attempting their task 
with far too little financial foundation. Is it not this in large measure 
that makes the visitor report: "Chemistry facilities are scanty and 
there is no evidence of proper apparatus for teaching physiology." 



78 PEKING UNION MEDICAL COLLEGE 

Or again, "The only laboratory is inadequate for a school with two 
hundred students." Or once more, "Equipment is scanty; and ex- 
cept for a minimum of practical instruction in chemistry, histology, 
bacteriology, and pathology, the teaching appears to be largely by 
lecture in the preclinical subjects." 

There simply are no funds with which to provide more. A recent 
investigator writes in the Journal of the American Medical Associa- 
tion that the government schools are like houses built upon the sand; 
that they are subject to every passing storm of revolution and 
political intrigue. In not a few their success and existence depend 
upon the health and strength of the man at the head. The salaries of 
the teachers depend upon the personal influence of the director. 
Surely, such conditions are not conducive to a forward movement. 
Outside of the Peking Union Medical College, the only foreign in- 
stitutions with a really adequate budget are the South Manchurian 
College at Mukden and the Medical School of Hongkong Univer- 
sity. And I fear their Deans will not agree to this statement as to 
their sufficiency. With the huge incubus of soldiers that now lies 
heavy on the land, the Chinese group of colleges will have great 
difficulty in securing funds enough to keep alive during the period 
just ahead; while the foreign colleges not associated with govern- 
ments are counting the cost anew. One, as has been stated, has 
decided not to continue. Two or three of the others look into the 
future in the hope that new funds will be forthcoming which will 
enable them to sustain and to increase their powers. 

What of the standards in force? Only six as yet require thorough 
laboratory preparation in biology, chemistry, and physics. The 
Chinese colleges are still satisfied to admit middle school graduates. 
But there are indications of higher standards, for a pre-medical year 
is soon to be required in one or two of them. In ten of the twenty- 
four colleges, the course lasts five years. In Mukden and Hongkong 
this is because, very naturally, the British pattern is followed. In 
the Peking Union Medical College didactic work lasts four years 
but a year of graduate work is required before the degree is con- 
ferred. Changsha and Tsinan are sure to follow this plan, together 
with St. John's, as soon as their teaching staff is adequate. The 
government colleges are all "special medical colleges," since there 



EVENING ADDRESSES 79 

is as yet no Chinese university medical school, and these special 
colleges still follow slavishly the Japanese model for that grade, 
that is, middle school graduation plus four years of medical study 
as the requirement for a medical degree. The former German college, 
with its reputation for high teaching standards and excellent equip- 
ment, has been revived. A new dean and new teachers have reached 
the field; and the work to be done there is likely to place the school 
shortly among the stronger institutions of the land. 

In the majority of the colleges the provision of lecture halls as 
compared with laboratories suggests that the imperative necessity 
of individual experimentation has not been sufficiently appreciated 
by the faculties. Belief in dissection is expressed everywhere, but 
actual provision for it is scarce. That physiology requires instru- 
ments of precision which every student must handle and that 
individual microscopes are needed by students throughout their 
courses is not fully realized, if one may judge by what he sees in 
most institutions. True, new laboratory buildings appear at several 
centers. Hangchow Provincial Medical College, for example, is to 
use its new buildings this autumn, but no anatomical laboratory 
with dissecting tables for every student is to be found there. The 
new college for women, also at Hangchow, consists essentially of 
recitation rooms. What gives one concern is not the simplicity of 
form or inexpensiveness of material in these new buildings, but the 
absence of any plan to let the student learn by personal experiment. 
The recently completed group of buildings for the province of Soo- 
chow and the group planned for the Board of Education College 
at Peking give promise of better provision, although in the for- 
mer, even the new laboratories do not furnish space and equipment 
enough for each individual student. 

In spite of the weaknesses mentioned, the teachers are on the 
whole a strong group. The Fellows of the Royal College of Surgeons 
in nearly every college where British take part and the correspond- 
ing Fellows of the American College of Surgeons in the institutions 
where Americans teach share the common task with French and 
Germans and Danes of distinction. Every college, however meager 
its budget or insufficient its staff, has teachers that would rise to 
high positions at home. In the majority of Chinese colleges, the 



8o PEKING UNION MEDICAL COLLEGE 

teaching staff consists largely of men trained in Japan. This is not at 
all unnatural when we remember what a stream of Chinese studied 
in Japan before 1914. It is nearer and less expensive to go there than 
farther abroad. Only a few of these teachers have had the oppor- 
tunity to study in the Japanese universities. Most of them are 
graduates of the special medical colleges, whose standards and 
equipments are moderate. Japanese medical leaders have made such 
remarkable contributions to the science of medicine (one of their 
eminent research men occupies a prominent place on this program) 
that we have a right to look forward to the day when Chinese who 
study in Japan shall come into close relationship with the master 
minds of that country. We need furthermore to make sure that the 
men who go abroad shall be picked men, that they shall be placed 
under such influences as shall weave inextricably into the fiber of 
their being those ideals for which the leaders of the profession have 
striven. Otherwise, and it is unfortunately true already, too many of 
the returned physicians from Japan, from Europe, and from America, 
slip back and complacently accept lowered standards, become 
afraid of their own powers and prove eventually not an aid but a 
hindrance to the winning of confidence for modern medicine! 

In research, the great field has been barely scratched. True, even 
from the earliest days, busy practitioners set themselves to wrest 
some secret from nature. Dr. Balme in his most valuable book, 
China and Modern Medicine, just published, divides the contribu- 
tions into historical, anatomical, physiological, and clinical. To his 
record I venture to direct those who wish to know the facts. Logan 
of Changteh was the first to find Schistosoma japonicum in China; 
Goddard of Shaohsing discovered an important new fluke. Cochran 
found in Hwai Yuen that the Leishman-Donovan bodies of kala 
azar could be detected in the superficial lymph nodes. And what 
shall we say of the researches of Manson, Cox, Maxwell, and a host 
of other workers? In Peking the search for new truth has actively 
begun. To take one example, the recent observations on the para- 
sites of Central China made by Dr. Faust during the past summer 
indicate how extensive is that single field. 

A few statistics will prove illuminating. In China there are twenty- 
four medical colleges, or one for every 15,000,000 of the population; 



EVENING ADDRESSES 81 

in the United States there is one for every 1,250,000 of the inhabi- 
tants; in Canada, one for every 1,250,000. And the majority of these 
twenty-four colleges have slender resources, insufficient equipment, 
and an inadequate staff. In the entire country last June there were 
2,050 medical students. This means only one student for every 175,- 
000 of the population. In the United States there are 14,872 medical 
students, one for every 8,000. In Canada there is one for every 3,700 
of the population. One thousand, one hundred and sixty-one physi- 
cians are listed in the 1921 directory of Chinese medical graduates, 
and perhaps as many more trained in Japan. Add to this 460 West- 
ern medical missionaries and the practitioners in a few large sea- 
ports, and the total number of physicians who are in a measure 
familiar with the principles of Western medicine does not exceed 
3,000. Here we have 3,000 physicians, poor and good together, in a 
population of not less than 360,000,000; one modern physician to 
every 120,000 of the population. In Great Britain there is one to 
every 1,100; in Japan one to every 1,000; in Canada, one to every 
1,050; and in the United States one to every 720. Measured in fig- 
ures the record is pitifully inadequate, but measured in terms of 
influence, of uplift and awakening in the nation, "it is questionable," 
says Dr. Balme, " whether there has been any other agency at work 
in China during the past century which has done so much as the 
practitioners of Western medicine to gain the confidence and good-will 
of the people and to dispel that miasma of fear and suspicion which 
beclouded all intercourse between East and West in former years." 
Even after the first few years of Peter Parker's activity in Canton, 
Beadle was led to say of him that he " opened the gates of China with 
a lancet when European cannon could not heave a single bar." 

Consider the move that is being made to extend government 
medical education. Partly through the plans of the Board of Educa- 
tion and partly through local initiative a program is being made that 
will include a medical college in every province. On October 22, 191 2, 
in the very first year of the Republic, a law was passed regulating the 
establishment and outlining the curriculum for medical colleges. 

Thinking people soon recognized that anatomical facts could not 
be guessed at. Pressure was brought to bear in Peking and in 1913 
the Minister of the Interior made dissection legal. It is gradually be- 



82 PEKING UNION MEDICAL COLLEGE 

coming an available teaching method. Officials in every city and stu- 
dents in all schools must be taught to appreciate how indispensable 
such dissection is and must be led to create favorable sentiment. 

In addition every hospital where earnest work is done is contrib- 
uting to the progress of medical education. They are springing up 
everywhere; government hospitals, both civil and military; private 
hospitals and even community hospitals. None of these are more 
conspicuous in excellence of management and medical supervision 
than the Central and Isolation Hospitals in Peking. 

Still another sign of the tendency to advance medical teaching is 
seen in the forming of a national committee on scientific terminology. 
This includes representatives from government institutions as well 
as missionary colleges and will soon put to flight the old confusion 
in nomenclature. 

Again, medical associations, both local and national, are spring- 
ing into being. Several of these are already issuing medical journals. 
True, much of this material is merely translated but original articles 
appear with increasing frequency. The journals of the Tung-chi 
College and the Tung-teh College in Shanghai are the most elaborate 
at the moment. Other useful journals are those issued by the 
colleges at Tsinan, Hangchow, and Soochow. Nothing more challeng- 
ing has appeared than an article in the Soochow journal arguing for 
the extension of medical schools. 

It is refreshing to discover, moreover, that increased financial 
support is being given to modern medicine. Over 50 per cent of the 
cost of upkeep of mission hospitals in China today is met with local 
funds, and 27 per cent of the hospitals meet all their expense locally, 
save for the salaries of the foreign staff. For the past nine years $300 
a month has been paid with the utmost regularity to the St. James 
Hospital, Anking; and this grant is soon likely to be increased to 
$500 a month. The military government and the provincial assem- 
bly share the grant. 

PRESENT ISSUES IN MEDICAL EDUCATION 

What are the fundamental issues in medical education in China 
today? First of all, the arousing of a sense of need — the awakening 
of the popular mind to the distressing lack of trained men and 



EVENING ADDRESSES 83 

proper facilities for the care of the sick. We have already seen that 
the proportion of physicians to the population is 120 times as great 
in England and Canada and Japan as in China. Dr. Dewey is right, 
it is essentially a matter of transforming the mind of China. In the 
schools that responded to the inquiry of Dr. C. V. Yui, only 1,153 
out of a total of 36,095 students indicated that they looked forward 
to the study of medicine. The leaders of public thought, educational 
authorities, pupils in schools, police magistrates, and all others who 
lead popular thought must be taught to recognize that a country's 
care for its sick and its program of preventive medicine is a public 
index of its advancement in modern civilization. Here lies the tre- 
mendous value of the public health program which Dr. Peter and 
his associates have been building up. They are arousing a public 
conscience and actually transforming the thought life of the com- 
munity. More young people in high schools must be influenced to 
study medicine. Engineers are needed, but the proportion of those 
planning this career as compared with that of the physician is far 
too great. The responsibility lies heavy on teachers and other guides 
to hold before the young students of this land the opportunity for a 
life of service in medicine as compared with the life of business or 
engineering where the financial rewards seem greater. 

The problem is largely a Chinese problem. The local educators 
and public authorities must be made to see the need. Only one- 
third of the colleges are mission colleges. The mission boards have 
entered the field of medical education. As we have already seen, 
theirs was the foundation on which modern medical education has 
been built. If their service is to be vital, to influence the methods and 
the standards of medical education in this great country, it must be 
increasingly effective. Every agency that is sending doctors to China 
must resolutely set apart more teachers for the medical colleges. Not 
by increasing the number of dispensaries where the foreigner can 
treat the sick himself, is China's need going to be met; but by an 
increased effort to train Chinese physicians, men and women them- 
selves to minister to their fellow-countrymen and women. If mis- 
sions are going to provide at all for medical education, they cannot 
afford to be so short-sighted as to attempt to increase the number 
of isolated hospitals when concentration of teachers in strong 



84 PEKING UNION MEDICAL COLLEGE 

groups at the teaching centers would make these institutions 
abound with vital energy that would kindle new life in the medical 
educational field of China. These students from China's own flesh 
and blood, and not physicians from afar, must be trained for service. 
Again, looked at from the point of view of missionary policy, no 
foreign influence can touch the life of an individual or a community 
in a measure that will compare with the influence of a Christian 
physician with wholesome professional standards. 

Either the eight mission colleges must be greatly strengthened or 
some of them must frankly admit that they face the alternative of 
closing or doing second rate work. One has already done so. Eight 
years ago the China Medical Missionary Association voted that 
until a designated group of eight colleges had been made strong, no 
new colleges should be started by mission boards. Such restrictive 
votes are unnatural so far as they limit initiative or prevent sound 
co-operation. Those who are charged with the administration of 
mission medical colleges should at recurring periods make such an 
unselfish study, setting aside personal feelings, in order to secure for 
China as great a number of medical colleges as can obtain sufficient 
staffs and funds enough to do sound work. 

The second great issue, closely related to the first, is that of high 
standards. For years Dr. Wu Lien Teh has been pleading for state 
control of education and practice. He has not had to go outside of 
China for his authority. Shen Tsung arranged for the establishment 
of medical schools in 1068 and his textbooks were prescribed by a 
central high medical court. The examinations were definite: one on 
the principles and one on the clinical practice of medicine and sur- 
gery; one on physiology and anatomy; one on differential diagnosis 
by the pulse; one on prescriptions and therapeutics; and one on the 
influence of air and stars. Those doing the best were given official 
medical positions, or were ordered to write or to teach; those of the 
second grade were licensed to practise; those who were unsatisfac- 
tory had to study their subjects again; while those who failed were 
ordered to change their profession. 

With such an illustrious example in mind, Dr. Wu has worked for 
central control; and no more significant document has appeared on 
this topic than his Memorandum to the Board of Education in 191 6. 



EVENING ADDRESSES 85 

Every teacher of medicine hopes he will live to see the realization of 
his ideals. At present there are no standards except those that indi- 
viduals or single institutions choose to make. There is no one to pre- 
vent the failed third-year student, the disgruntled nurse, or the 
charlatan who steals a doctor's cast-off instruments and sets him- 
self up as a practitioner, guaranteeing to cure all manner of outer 
ills, from claiming to be a doctor of medicine. Tuan Fang tried in 
1908 to revive the licensure law of the Tsing dynasty imposing a 
$500 fine on those physicans who did not register; this refers, of 
course, to the physicians of the old school. He had 900 men exam- 
ined and graded into five groups, the two lower being forbidden to 
practise. Do we suppose that they have continued to hearken to the 
prohibition ? 

What are we to do in these days of waiting? Every college, every 
teacher, must make it his personal responsibility to develop ideals 
and the power of sustaining them in every student. Every graduate 
must be aided to live up to the ideals with which he left his college. 
This can be accomplished in part by faithful advice as to the hos- 
pital where each graduate shall take his interneship, and later prac- 
tise, in part by insisting that he read the literature, and in part by 
encouraging frequent visits to his alma mater and to other colleges. 
The colleges themselves must be kept as fountain-heads of inspira- 
tion. Among those who shape the standards the essential need is for 
leaders who shall face boldly the minimum requirements for main- 
taining modern standards in their particular centers, and for pro- 
viding laboratory space for each student in every one of the funda- 
mental branches of science; and who shall then either convince the 
authorities that sums must be provided to meet these expenses; or 
frankly admit that the school cannot live up to modern require- 
ments. Gathered as we are in one of the most perfectly equipped and 
efficiently manned medical colleges in the world, our vision has al- 
ready been broadened. We find ourselves reaching new conceptions 
of what the standards of a teaching institution should be. Remote 
though the time may be when other colleges can have a plant or a 
staff even distantly approaching the ideal set before us here, they 
may receive refreshment and be stimulated to fresh endeavor by the 
touch with Peking. 



86 PEKING UNION MEDICAL COLLEGE 

Consider for a few moments the service this college in Peking may 
render, nay, must render. In his Report of 1920, Dr. Vincent has al- 
ready outlined a program. The college is (1) to give undergraduate 
medical teaching, (2) to provide in due time for graduate teaching, 
(3) to offer short courses for physicians, (4) to afford reasonable 
opportunities for the study of Far Eastern diseases, (5) to extend a 
popular knowledge of medicine and public health, (6) to promote 
research. But the aim is stated even more completely in two other 
brief phrases: "It ought to become a rallying point for medical train- 
ing and research for the entire Far East"; and again, "a station in 
the world-wide system of medical education and research." 

Let me venture, as one whose major interest is medical education 
in China, to indicate at this point, some of the special directions in 
which the medical world of the Far East may receive inspiration, at 
this station, this rallying point. Of course the primary aim of any 
medical college is to produce doctors. But fundamentally, this in- 
stitution must uphold the spirit of investigation. I mean something 
far more than mere study into the nature and treatment of disease. 
Here should grow up the laboratory where inquiry will be made into 
the curriculum needed by the particular type of mind with which 
we have to deal in China. Here it will be possible to investigate the 
student himself, his attitudes and his responses to one and another 
type of teaching, his points of weakness and of strength. Chinese 
when well trained make good physicians and surgeons. We have all 
seen this in our wards and operating rooms; but they have not yet 
shown those qualities of imagination and initiative so essential in 
starting an independent growth. Nor have they developed that 
power to sustain which is indispensable in carrying on an enterprise 
launched with enthusiasm and abundance of initial support. 

In Peking, then, we shall be able to determine the methods best 
adapted to our Chinese student. Here, too, the student will apply 
himself, by the experimental method, to the development in himself, 
and in his group, of those characteristics that are vital in forwarding 
modern scientific education. Such human research cannot be done 
abroad. The teacher in Peking will be free from the demands of 
practice and can give his whole time to the task. He will learn how to 
teach as well as what to teach his Chinese student, who comes of a 



EVENING ADDRESSES 87 

race in whom memory development is phenomenal, but whose entire 
method of study is henceforth to be in preparation for the making 
of sound and prompt judgments, for decisive and purposeful action. 

Again, the teacher in Peking will discover how to modify his cur- 
riculum. We are all too prone to transport to a new field the recollec- 
tion of what we were taught, to reproduce an arrangement of courses, 
a proportion of teaching hours almost identical with that which we 
learned somewhere else. But here in China economic conditions are 
different, climatic conditions are different: must we not make at this 
center investigations that will enable teachers throughout the coun- 
try to formulate courses adapted to the local needs? Must not the 
eye receive a major share of attention? (Dr. Howard tells me that of 
all cases examined in Peking, $$ per cent have trachoma!) Will not 
parasitology, and its allied branches of helminthology and protozool- 
ogy, claim a much larger share of time in the curriculum than in 
Western lands? The nervous system diseases of China have just be- 
gun to receive attention. When we think of the variety of nutri- 
tional and parasitic influences likely to have caused these maladies, 
we shall realize the emphasis they need and the abundant facilities 
necessary for those who undertake to shed light upon them. 

And what shall we say of the vast field of pharmacology? Hardly 
a day passes without our hearing of some Chinese remedy of unusual 
potency, a drug that is reported as able to restrain the pernicious 
vomiting of pregnancy, a certain stone-like fungus that will expel 
round worms, a powerful diuretic, an herb that will reduce fever. 
For the trained pharmacologist, associated with the biological 
chemist and the botanist, the field of inquiry is infinitely large; and 
the psychological effect upon our Chinese friends, teachers and lead- 
ers of public thought as well as physicians, of such inquiry into the 
worth-while elements of the Chinese pharmacopeia, will be most 
surprising. 

As regards investigation, here men will study how to adapt hos- 
pitals and dispensaries to the Orient, how to fit the laboratories to 
the needs of China, how to make them most serviceable in hot damp 
summers and cold dry winters. Here, also, we shall continue to study 
the food that the Chinese are eating, the nutrition their bodies need; 
and these findings will be made in the light of the economic condi- 



88 PEKING UNION MEDICAL COLLEGE 

tions we find in China. The chemist and dietitian and physician and 
nurse will meet in vitaminal fellowship with the student of economics 
and meteorology. In Peking, too, we shall test out matters still un- 
settled in the field of nursing. For here alone have we nurses enough 
to provide supervision for pupils in training. We shall know from 
the experiments here whether women nurses can be used in all the 
wards. The actual nursing needs of the group of hospitals through- 
out China have had to be met so rapidly since 1909, when the 
Nursing Association of China was formed, that there has scarcely 
been time for a laboratory study of the essential problems of adap- 
tation. 

"A rallying point" indeed! Not a place where the physical needs 
of the individual sufferer are to receive less attention than in a 
mission hospital, because this happens to be a center of research; 
but rather ?nore. For all his needs, and the way in which they are 
to be met, can be studied here. His social setting, his economic 
status, his moral and religious nature, are to be ministered to here. 
In this connection I venture to point out that the newer methods 
being followed in this hospital by the Director of Religious and 
Social Work, should prove suggestive to every medical missionary. 
Without compulsory attendance at a traditional preaching service, 
friendship is extended in a personal way to each patient. As the re- 
sult of such contacts there was a remarkable number of in-patients 
last year who voluntarily related themselves after leaving the hos- 
pital to the Christian community in Peking and elsewhere. 

"A station in a world-wide system!" The hospitals established 
by medical missionaries throughout the land, which constitute both 
the advance guard in all outlying districts, carrying constantly 
farther the needs and spirit of modern medicine, as well as the 
foundation upon which medical education is being built, are looking 
to this institution. They are hopeful that the graduates leaving 
these halls shall be filled with the spirit of service rather than that 
of personal glory. At the present moment, it is difficult for graduates 
trained by European and American teachers to find their way into 
government positions. Such unwillingness to recognize these grad- 
uates occurs partly out of a temporary failure to appreciate that 
true medicine is all one and that those who are imbued with the de- 



EVENING ADDRESSES 89 

sire to seek truth must be given an equal chance to prove their 
worth. In the meantime, however, nothing is more essential than 
that graduates from schools with high standards shall be encour- 
aged to serve in that same spirit of self-forgetfulness which charac- 
terized the early medical missionaries. If the hospitals in many 
cases lack facilities and staff sufficient to make them worthy prac- 
tice grounds for our better graduates, let the institutions be strength- 
ened; let each graduating student receive an impulse that will send 
him to them. Through these hospitals, particularly the mission hos- 
pitals, the spirit of modern medicine that is essentially the spirit of 
Christian ministry, can better be made known to China, can have 
a larger share in uplifting the masses, than by placing them in any 
other position. We must hope that many will also eventually find 
their way into government positions, but until these positions can 
encourage men to serve rather than to become self-complacent and 
self-seeking, we are in danger of ruining both the professional and 
moral fiber of those who graduate from our care. 

In such measure as its facilities will permit, every medical college 
in the land must assume responsibilities similar to those which have 
been indicated for this model institution in Peking. At Mukden and 
Tsinan, at Shanghai and Changsha, at Chengtu and Hongkong 
and Canton, the same challenge is put before us. Grateful as every 
practitioner and medical teacher in China must be to those far- 
sighted Trustees of the Rockefeller Foundation who conceived and 
carried through the plan for this institution, the opportunity is now 
theirs, whether they are associated with government colleges or 
mission colleges, community hospitals or private hospitals, to relate 
themselves to it, to take advantage of the privilege of working within 
it, to co-operate with it, and together with its staff to develop a new 
basis for work in China and to generate, in fellowship, new inspira- 
tion for those whom we teach. 

Time does not suffice to do more than allude to a very few other 
pressing questions: 

1. The language through which medical instruction can best be 
given is still an open question; not perhaps as to the ultimate 
medium, but as to the time and the way for giving up English in a 
college like Peking; or, in the case of a college like Tsinan, as to the 



go PEKING UNION MEDICAL COLLEGE 

method for increasing the ability to use English or some other 
Western tongue. The one essential is that the graduates shall relate 
themselves to the medical needs of their own people on the one 
hand, and on the other that they shall always live as students seek- 
ing continued contact with the productive minds of the medical 
world. 

i. Relationships with the group of physicians trained in Japan 
must be made more cordial. Whether this shall be done by selecting 
them for our teaching staffs, either as regularly appointed instruc- 
tors or as extra-mural lecturers, remains to be determined. There 
must be only one national medical association and good men must 
be given access to posts that need them, irrespective of the place of 
their training. 

3. A method must be found by which more technical training can 
be provided for the army of assistants required in the hospitals of 
the land. There are 326 mission hospitals and 244 additional mission 
dispensaries in China, not to mention the scores of hospitals that have 
grown up through private or community initiative. In far too many 
of these the professional men and women are giving too much time to 
laboratory tests, to the mere mechanics of radiology, to bookkeeping 
and other administrative matters, to make it possible for them to do 
the work for which they are trained. Shall the medical schools set 
themselves definitely to training the technical assistants needed, or 
shall there be a new institute in some center not related to a medical 
college, where technicians and administrative workers may be 
trained? Graduates from such a school must be prevented from at- 
tempting functions beyond their powers, and, on the other hand, 
such centers must not draw away from medical colleges men and 
women who ought to be set apart for these teaching staffs. The 
awakened sense that better work is required than formerly makes 
the hospitals send out an appeal that their needs be met. Medical 
colleges must take the lead in meeting their demands. 

4. A new program of pre-medical instruction must be drawn up 
for the whole country. Every medical college ought to turn over 
work of this kind to a college of arts and sciences, in order to free it- 
self from the financial and administrative responsibilities involved 
and more particularly to give the student preparing for medicine the 



EVENING ADDRESSES 91 

stimulus and cultural background of college associations. Surely it 
is not a normal thing to take a student out of the middle school and 
to isolate him within the confines of technical training for seven or 
eight years. He must be thrown as long as possible with students 
and teachers that represent the variety and complexity of the life 
into which he is going later on. Colleges whose pre-medical science 
facilities are still inadequate must be made strong and enabled to 
take their share in a large plan which will train both for medicine 
and other sciences. In this connection a method must be devised by 
which the science work and the other departmental work of our 
colleges shall be described in such a way that each may understand 
what the other is doing. Some central committee or. officer may be 
necessary to aid the scattered institutions to bring their work up to 
certain standards and to enable teaching staffs to understand each 
other. 

5. The medical education of women is an issue already looming 
large in the Peking Union Medical College. The Pre-Medical 
School has now quite a number of women among its students. No 
sooner had Changsha thrown open its doors than inquiries were 
received and two women pre-medical students began work there 
last week. The same experience will be found throughout the land. 
There is a very strong feeling in some quarters that in addition to 
such facilities for co-operation in certain medical colleges, at least 
one medical college for women should be maintained. If funds and 
an adequate faculty can be secured there would appear to be no 
argument against such a move; but, in passing, it is worthy of note 
that the tendency to strengthen medical colleges exclusively for 
women is diminishing rather than increasing in Western lands. 

6. A program for securing pupils to enter upon the study of medi- 
cine must be laid down. We must find in the middle schools through- 
out the country those which have mental breadth and initiative 
and win some of them for our profession. In his inaugural speech at 
Yale University last June, President Angell said, "It is obviously 
futile to look for intellectual leadership from men of second-rate 
capacity. * * * * No university is quite worthy of the name and 
none is serving to the full its own day and generation, that is not 
through its productive scholarship, enriching human life and en- 



92 PEKING UNION MEDICAL COLLEGE 

larging the borders of human understanding." Are we making an 
inclusive plan to find such minds for the medical profession in 
China? 

FUTURE REQUIREMENTS 

As regards the future, three things seem clear: 

i. The future of medicine must be in Chinese hands. Medical 
missions alone can provide only scantily for medical education. 
Their finances and, in a measure, their aims, do not justify setting 
apart an indefinitely increasing number of men for this particular 
type of service. A single school like the Peking Union Medical Col- 
lege can inspire and lead, but can cope with only a small fraction 
of the need. Let every medical teacher, Chinese and foreign, bend 
his energies to the development of a national medical policy. On 
the one hand this will involve a central council to devise stand- 
ards and examine candidates for licensure; on the other it will in- 
volve new co-operation by which Western workers will seek to 
adapt their contribution to the Chinese situation and will offer aid 
to the strengthening of Chinese forces, inspiring local leadership in 
province after province and putting upon it the responsibility for 
advance. 

2. Only schools with high professional standards should be coun- 
tenanced. For a time the product will be numerically inadequate, 
but will it not be inadequate even if we multiply our forces ten-fold 
or twenty-fold? Shall we not rather, whether government forces or 
mission forces, make the work that we do memorable for its excel- 
lence? Can we not devise, as the administrators of The Rockefeller 
Institute in New York have devised, a plan by which our work shall 
continually be held up and our leadership made to depend upon the 
character of the work we do ? 

3. The motive of our work must be continually restated. Hear the 
utterance of the President of the Rockefeller Foundation: "The 
greatest need of China is not, after all, for highly trained scientists, 
although they are essential; it is not, after all, for the greatest 
technical skill, although that is absolutely necessary if the great end 
is to be attained. But the great need of China is scientific knowledge 
and technical skill dominated by idealistic loyalty to the highest 
and best influences in human life; and that idealism that is most 



EVENING ADDRESSES 93 

enduring, that can be most counted upon, that is least likely to fail, 
is an idealism based upon a deep and abiding religious conviction." 
"The profession of medicine," says Monsieur l'Abbe Hue in the 
record of his travels in China, "is considered an excellent conduit or 
waste pipe to carry off all the literary bachelors who cannot attain 
to the superior grades or pretend to the mandarinate; and China is 
consequently swarming with doctors, even without counting the al- 
most innumerable amateurs." Those old days are going. We cannot 
afford to have amateurs any longer. To banish them wholly, we need 
a new consortium. It must be a consortium of medical educators 
from China and Japan and Europe and America who will take part 
fearlessly and with devotion in shaping the traditions of the pro- 
fession. In leading new candidates into it, we, too, must have knowl- 
edge and skill and show that we ourselves are under the domination 
of a deep and abiding idealism. 



MEDICAL EDUCATION IN THE DUTCH EAST INDIES 

By 
A. de Waart, M.D. 

EARLY MEDICAL EDUCATION 

Medical education in the Dutch East Indies was first started by 
the Government as a two-year course on behalf of the so-called 
"doktors-djawa," or Javanese doctors. Instruction was given in the 
Military Hospital at Weltevreden (Batavia) by military doctors in 
the Malay language. The aim was to provide a number of vaccina- 
tors against smallpox. But very soon facts showed that these men 
were often forced by circumstances to practice medicine to its full 
extent, on account of the insufficient number of properly qualified 
physicians. Therefore it was necessary to improve and enlarge the 
scheme of training. 

In 1864 the original two-year course was lengthened to three 
years. In 1875 the course of study was divided into a two-year pre- 
medical course and a three-year medical course. At most, one 
hundred native boys, having passed through a native primary 
school, were to be admitted. The Dutch language was to be used for 
instruction in the medical course, as the Malay language showed 
too great a deficiency in equivalents for scientific, technical, and 
abstract terms. The number of military medical teachers was in- 
creased from three to five, and these were all only half-time men. In 
1 88 1 the pre-medical course was lengthened to three years. However, 
the members of the Committee for the final examinations repeatedly 
complained of the unsatisfactory results obtained, and continued to 
urge changes in the curriculum. 

Of great influence upon the subsequent growth of the school was 
the government resolution of January 15, 1888. By means of this the 
temporary laboratory, which had been fitted up in the Military 
Hospital for the investigations on beri-beri by the Dutch professors, 
Pekelharing and Winkler, was made into a permanent one for pa- 
thology and bacteriology. At the head of this laboratory two civil 
medical officers were placed as director and subdirector, who were 

94 



EVENING ADDRESSES % 

to be at the same time director and subdirector of the doktor- 
djawa school. They were appointed in addition to the staff already 
existing; this meant an increased number of teachers, and gave also 
a greater stability to the staff, as those two members were not likely 
to be transferred. The director then appointed was Dr. C. Eykman, 
later professor at the Utrecht University. 

However, teaching in the native primary schools proved insuffi- 
cient for matriculation in the pre-medical school. So at the instiga- 
tion of Dr. Eykman only native pupils of the Dutch Government 
primary schools, where instruction started at once in Dutch, were ad- 
mitted to the pre-medical course (1890). The pre-medical course was 
reduced again to two years, which however proved later to be a mis- 
take. In the same year, 1890, the practical medical and surgical 
training was greatly improved by providing accommodations for 
medical and surgical dispensaries in the military hospital. 



REORGANIZATION 



In 1896 Dr. Eykman was succeeded by Dr. Roll, whose reorgan- 
ization proposals led to the following changes: 

1. The alteration and enlargement of the existing rooms in the 
Military Hospital, so that the number of students could be in- 
creased to 150. 

2. The building of a new school, a suitable site for which was 
found on the Hospital Road, using part of the Hospital gardens. 

This new institution, where 200 students found ample room, was 
opened with due ceremony on March 1, 1902. The junior students 
shared the common lofty dormitories, the senior students had sepa- 
rate cubicles. A recreation hall was at the disposal of the pupils out 
of school hours. 

The situation of the new school in the immediate vicinity of 
the military hospital made it possible for the out-patients, whose 
number greatly increased, and who received treatment in the dis- 
pensaries of the new school building, to be taken to the wards of the 
military hospital in case of need. Furthermore, it allowed the clini- 
cal classes to continue in the military hospital buildings, and, as 
before, the military doctors could retain their positions as half-time 
teachers. 



9 6 PEKING UNION MEDICAL COLLEGE 

In the military hospital the maternity ward for wives of soldiers 
was enlarged and material for practical lessons in obstetrics was 
ready at hand. It is a curious fact that, although everyone was con- 
vinced of the ignorance of the native midwives, still, up to that time, 
no obstetrics were taught at the school, and consequently the dok- 
tors-djawa were not qualified for this part of medical practice. 
Only a few didactic lectures on obstetrics had been given and the 
subject had been optional. In the year 1902, practical teaching of 
obstetrics was arranged, and it became an obligatory subject for the 
final examination. The graduates now received the degree of "In- 
landsch Arts " (native physician) with full authority to exercise their 
profession as doctors in medicine, surgery, and obstetrics. 

In the new school more care was bestowed on laboratory work in 
physics and chemistry as an indispensable foundation for the subse- 
quent study of medicine. 

3. The pre-medical course was again lengthened to three years. 
In order to be admitted the pupil had to pass through a Dutch 
primary school with a seven-year course; and in 1903, moreover, a 
matriculation examination was instituted. 

4. An extra year was added between the third and fourth of the 
medical course in order to obtain more logical sequence in the order 
of the subjects. This made it easier for the students to follow the 
teaching, although the medical course was in this way lengthened to 
six years. Now for the first time general pathology was taught before 
clinical subjects. More time could also be given to the latter subjects, 
especially to elementary clinics in the fourth year. 

5. Practical experience had shown that the measure, instituted 
on the advice of Pekelharing, to unite the directorship of the Labo- 
ratory and of the Medical School in one position was a mistake; it 
was impossible for one man to fill both posts at the same time and 
do the work properly. A special director for the school was therefore 
appointed in 1901. Moreover, the number of teachers was increased 
with five full-time men. 

6. Furthermore, the course in legal medicine was improved with 
a view to requiring a high degree of efficiency from the graduates. 
Legal medicine also became an obligatory subject for the final ex- 
amination. 



EVENING ADDRESSES 97 

The fact that since this reorganization the percentage of success- 
ful students rose from about 20 to about 48, or 8 per cent of the total 
number admitted in the pre-medical course, proves clearly that the 
new measures were greatly to the advantage of our medical educa- 
tion. 

THE SECOND MEDICAL SCHOOL 

In 1913 the Government of the Netherlands East Indies appointed 
a committee to advise on the question of a second medical school in 
order to increase the number of qualified physicians more rapidly. 
The advisers wished to accomplish this aim without lowering the 
standard of efficiency. In principle the Committee even wished to 
raise the standard in view of the great responsibilities and the large 
number of serious duties the native physicians were called upon to 
meet in their daily routine. 

Following the advice of the Committee the second Netherlands 
Indian Medical School was opened in Sourabaya; and the schools at 
Batavia and Sourabaya were reorganized. Experience had shown 
that the first year of the medical course still produced unsatisfac- 
tory results. The cause of this was a hiatus between the pre-medical 
and medical instruction. 

A so-called propaedeutical class was therefore introduced as a link 
between the pre-medical and medical schools, now as a rule consid- 
ered the first year of the medical course, which now consists of seven 
years' study, making the entire course ten years after the seven years 
in the primary school. The principal subjects taught in this propaedeu- 
tical class are mathematics, physics, chemistry, and biology. It was 
rightly expected that the institution of the propaedeutical class 
would facilitate the work of the students, since a sounder foundation 
was laid beforehand and the sequence of the subjects taught was 
arranged far more logically. For instance, physiology could now be 
started after very complete instruction in physics and chemistry. 

We know from experience that under the present regime students 
get greater profit from their instruction, because the difficulties are 
brought more gradually within their grasp. The failures at the 
whole school and at the final examinations are fewer than ever 
before. I must insist strongly on this fact because outsiders have often 
maintained that the course of study is too long. 



98 PEKING UNION MEDICAL COLLEGE 

In 1913 medical study was opened to students of all races, including 
Europeans and Chinese; girls were also admitted, as well as students 
for free practice, paying fees and not bound by indenture to the 
Government. All graduates now received the degree of "Indisch 
Arts" (Indian doctor of medicine). 

Laboratory work was placed on much broader lines. Do things for 
yourself, see for yourself — this should be the motto of all good 
medical education. There was no theoretical book-learning, but 
constant exercise of the perceptive faculty, the acquiring of deftness, 
perfect practical knowledge of instruments, and scientific methods 
of research, no acceptance of facts on authority, but independent 
personal investigation. Laboratory work was improved in all 
branches of study. 

Very soon our buildings at the Hospital Road in Batavia became 
too small to accommodate the constantly increasing number of 
students and to provide at the same time sufficient room for labora- 
tories. Sometimes in only one laboratory, seven teachers followed 
each other for practical lessons. No wonder that the preparations 
for these lessons presented enormous difficulties and that very little 
time was left for them, and neither time nor room was available for 
research work. Everyone connected with the school in Batavia 
looked forward to the possession of buildings, where the work of 
medical education could grow and develop without impediment or 
hindrance. 

FURTHER PROJECTS 

The late director, Dr. Noordhoek-Hegt (deceased in 191 5), 
evolved a plan for the combination of new school buildings, with a 
laboratory of public health and the new Central Civil Hospital at 
Salemba (Batavia). 

An entirely new group of medical buildings was projected and 
built. 

In 191 8 the Laboratory of Public Health; in November, 19 19, the 
new Central Civil Hospital; and in July, 1920, the new medical 
school buildings were put into use. The arrangements in these 
buildings provide against all the difficulties we had to cope with 
at the Hospital Road. Our main building contains laboratories, 
museums, and lecture-rooms for physics, chemistry, biology, 



EVENING ADDRESSES 99 

physiology, physiological chemistry, pharmacology, and pharmacy, 
and also on the first floor classrooms for the pre-medical school. 
Over the principal entrance hall is built the aula, used for official 
ceremonies, awarding of doctors' diplomas, etc. In August, 1921, 
were held the full meetings of the Fourth Far Eastern Tropical 
Medical Congress. 

Behind the main building is the building for anatomy, pathologi- 
cal anatomy, legal medicine, bacteriology, and hygiene, with labo- 
ratories, lecture-rooms, museums, and libraries for all these branches. 
Our large dissection hall for anatomy allows sixty students to work 
together, and is better equipped than that at any university in 
Holland. The autopsy-room and morgue are near the hospital. 

The clinical lectures are given in a building in the center of 
the hospital grounds, reducing to a minimum the transport of the 
patients needed for demonstrations. The hospital wards now con- 
tain about eight hundred patients, whereas twenty thousand new 
patients last year came to the dispensaries. The senior students have 
daily to be in the wards and dispensaries, and get plenty of oppor- 
tunity for bedside work, operations, etc. Laboratory work and 
Roentgen examinations are performed in special rooms in the hos- 
pital. 

Our new operating rooms for surgery, obstetrics, and ophthal- 
mology will soon be ready. Graduate work is being carried on in the 
clinical branches, especially by European doctors, studying tropi- 
cal diseases. More and more native physicians are to be added to the 
teaching staff as assistants. The staff requires enlargement to give 
more time for research work, for which laboratory equipment in 
some branches is already quite sufficient; in others, for instance in 
physiology, there is still need of improvement. On the opposite bank 
of the River Tjiliwong, facing the medical buildings, will be erected 
up-to-date student-homes for 300 pupils. 

PRESENT MEDICAL CURRICULUM AND ENROLMENT 

The medical curriculum in Batavia is now very complete, none of 
the modern medical subjects is omitted in our curriculum. Last year 
we introduced an optional course in dentistry, improved our instruc- 
tion in ear, nose, and throat diseases, and greatly enlarged our out- 



ioo PEKING UNION MEDICAL COLLEGE 

patient work in obstetrics. In the pre-medical course English and 
German were taught as foreign languages. The school in Sourabaya 
will in due time have the same curriculum, but it has no residential 
system, and the buildings are not yet sufficiently equipped. They 
will, however, be ready in about four years. 

There are now in Batavia more than 300 students of all races, 
male and female. Two hundred live in the dormitories, which are 
still in the old school buildings. They can pursue the courses at their 
own expense or be indentured to the Government. The indentured 
students enjoy free tuition and are provided with books, etc., free of 
cost. Moreover, they receive an allowance for food and dress. After 
obtaining their degrees they have to serve the Government for as 
many years as they have studied. They can, however, go into pri- 
vate practice if they pay back 650 florins for each year of study. 

All graduates have the right to unlimited medical practice. 
Whenever they desire to have the same position in Government 
service as the Dutch doctors, they must first obtain their diplomas at 
a Dutch University. Twenty-three of our twenty-six graduates, who 
went to one, did this inside of only a year and a half. Dutch pro- 
fessors, with whom we are in permanent exchange as visiting lectur- 
ers, are very well satisfied with our students and graduates. In 
special cases fellowships are given for study in Holland. 

(Here fifteen pictures of the medical buildings in Batavia were 
shown on the screen.) 

I am very much indebted to your honored President, Dr. Vincent, 
who has made it possible for me to give this lecture. I hope it may be 
of some use in making a connection among the various medical 
educational institutions of the Far East. Without doubt the educa- 
tional and practical problems we have to face are often the same, 
and mutual knowledge may lead to mutual help and better under- 
standing. We shall be proud to co-operate with the brilliant and 
well-equipped institution which the Rockefeller Foundation is now 
starting in Peking, and to help each other in improving medical 
education, medical science, and public health in the Far East. 



AN ADVENTURE IN PUBLIC HEALTH 

By 

George E. Vincent, Ph.D. 
[an abstract] 

Yellow fever, known for nearly two centuries, has been a scourge 
in Mexico, the West Indies, Central and South America, and has 
several times invaded the United States. 

The discovery in 1901 by United States Army doctors in Cuba 
that yellow fever is transmitted by the bite of the female stegomyia 
mosquito; and the successful sanitation under General Gorgas, first 
of Cuba and then of the Panama Canal Zone, prepared the way for a 
larger campaign. 

In 1916 the International Health Board of the Rockefeller Foun- 
dation commissioned General Gorgas to make a survey of the yellow 
fever situation with a view to organizing control measures on an 
international scale. 

The Commission reported that the seed beds of the disease were 
relatively few and well known. A concerted attempt to eradicate 
the disease from these endemic centers was recommended. 

After a delay due to the world war General Gorgas, in the autumn 
of 191 8, was placed at the head of a special yellow fever commission 
to undertake a campaign of elimination. 

He visited Central and South America, organizing in each coun- 
try a national commission which served as a means of co-operation 
in a unified effort at control. 

Meantime Noguchi of The Rockefeller Institute for Medical 
Research had made field investigations in Equador and Mexico, 
had isolated the germ of yellow fever, and had prepared a vaccine 
and a serum. 

The principal attack was made under Connor in Guayaquil 
toward the end of 19 19. This city had been the chief source of 
yellow fever for a century and a half. By July, 1920, the well- 
organized anti-mosquito work had freed the community of the 
disease. 



102 PEKING UNION MEDICAL COLLEGE 

Sporadic outbreaks and local epidemics in Central America, and 
a serious situation in Northern Peru were effectively dealt with by 
White and Hanson. Late in 1920 Mexico invited co-operation, so 
that the organization was completed. 

Gorgas on his way to investigate a suspected area on the West 
Coast of Africa, died in London in July, 1920. He did not live to 
"write the last chapter," but he did see gratifying progress made 
toward the realization of his dream. 

Political leagues are still causes of dissension, but there are hope 
and promise in a league for health which seeks to turn science 
from the arts of destruction to the healing of the nations. 



METHODS OF VISUALIZING MODERN HEALTH IDEAS 

By 

W. W. Peter, M.D. 

In China, where modern health ideas and practices have not been 
generally applied, ignorance and superstition are important factors. 
The methods I shall demonstrate have been developed gradually by 
the Council on Health Education since 1914, and constitute an 
addition to the usual methods of using literature, charts, posters, 
lantern slides, and moving pictures. They have been used in pre- 
senting the relation between national health and national strength 
to approximately six hundred thousand people. 



PRELIMINARY ORGANIZATION 



The following is the usual beginning. A small group of citizens in 
a community, desiring to begin improvement in health conditions in 
their city, appeal to the Council for help in conducting an educa- 
tional campaign. A central committee composed of the leading 
officials, educators, business men, and missionaries is organized. In 
Foochow, 1,847 volunteers were enlisted. Two hundred and forty- 
seven meetings were held in one week, attended by 110,000 people, 
admission being by tickets distributed through schools, police 
officers, and churches. The purpose of that campaign was to fight 
cholera which manifested itself the previous year in about fifteen 
thousand cases. This executive committee pays all expenses ranging 
from several hundred dollars to $3,500 (in Foochow). The Foochow 
committee developed special methods, such as the use of a health 
parade with twenty-eight floats carried by coolies through 90 per 
cent of the streets of the city during one week. Each float visual- 
ized some one fact about cholera. But generally the backbone of the 
educational campaign is the demonstrated lecture, "Some Rela- 
tions between National Health and National Strength." A transla- 
tion of this lecture which follows indicates the simple, direct phrase- 
ology which has proved most effective: 

103 



io 4 PEKING UNION MEDICAL COLLEGE 

THE LECTURE 

Two Kinds of Citizens 
Every community has two kinds of citizens. There are those who 
are well; they are like this lamp which is clean, provided with the 
right kind of fuel, and kept properly trimmed. Here is a model of a 
citizen of this kind. Then there are those who are sick. They are like 
this smoky lamp which is of no use to anybody. Here is a model of 
the second class of citizens. He has had smallpox. He has trachoma. 
He may have tuberculosis and quite likely has intestinal parasites. 
Impeded in this way he cannot get rich, take good care of his family, 
send his children to school, or be of any great help in building up 
this city. Every city has these two classes of citizens and their rela- 
tive proportion determines to some extent the degree of happiness 
and prosperity possible in that city. 

China s Load 

[A poorly dressed man of diminutive figure comes upon the platform. He car- 
ries a heavy load, his back is bent and he walks very slowly.] 

China is impeded in every step she is trying to take by an extraor- 
dinarily heavy load of disease. Every nation has its load of disease 
but in some countries sufficient attention has been paid to a study of 
the load to determine its exact nature and to discover ways whereby 
it may be lightened. Of what does China's load of disease, consist? 

[The bag, tightly shut, disregarded for ages, is slowly opened. Huge blocks of 
wood are removed. Each one has characters written on four sides. There are 
blocks to represent smallpox, cholera, plague, typhus, hookworm, trachoma, 
typhoid, etc. Difficulty is encountered in removing some of the blocks like tuber- 
culosis.] 

Some parts of this load are exceedingly difficult to remove. If I 
were to bring in representatives from other nations you would see 
that not all of their loads have been removed. But it is a question 
whether the load of any one of them would be quite as large as this 
one for the very simple reason that in other countries the people are 
constantly at the task of lightening the load year by year, whereas 
in China we have not really begun in earnest. But if China is to be- 
come a strong nation this load must receive consideration; no nation 
can make permanent progress if it is thus impeded. 



EVENING ADDRESSES 105 

Death-Rates in Strong and Weak Nations 

A famous Chinese sage has said, " the strength of a nation is its 
people." One way to measure strength is to ascertain how fast it is 
being lost. A study of strong and weak countries will reveal an as- 
tonishing fact. All strong nations have a low death-rate, and all 
weak nations have a high death-rate. I should also add that it is 
easier to ascertain the death-rates of strong nations because they 
make it a practice to employ trained men to do this kind of vital 
bookkeeping, while weak nations do not. 

[From metal boxes suspended from a high rack on the platform hinged wooden 
plates are dropped. These plates are 6 by 8 inches in size. On one side white skulls 
are painted on a colored background. The first skull to appear is in profile and each 
additional skull approximates a front view. Thus the death-rates per thousand are 
visualized for England, Germany, and America, representing three strong na- 
tions. At the opposite end of the rack are boxes representing Mexico and India, 
with death-rates approximately double those first shown. In the center, between 
the strong and weak nations is a yellow box representing China.] 

What is the death-rate in China? No one knows. It is said to be 
40 per 1,000 per year! I have not placed China among the weak na- 
tions nor among the strong. It remains for you to determine her 
place in the future. 

Relative Population 

But some of you are thinking: "What difference does it make if 
China has a death-rate higher than most countries? We can easily 
spare those who die. We have a 400,000,000 population. China has 
too many people. A high death-rate is heaven's way of maintaining 
an equilibrium. It would be exceedingly dangerous to interfere by 
applying such modern health conservation practices as obtain in 
other lands. What should we do with all the people whose lives would 
inevitably be saved thereby? There is no room for them." 

Is China overpopulated ? 

Let me try to answer only one part of this question, namely the 
actual population per square li (one-ninth of a square mile), as com- 
pared with other countries. 

[Two tables are brought out. They are of the same size, about 4 feet square. One 
is colored red to represent Europe and the other yellow to represent the Orient. 
The tops of the table are perforated by holes, ten holes to a row and ten rows. The 



106 PEKING UNION MEDICAL COLLEGE 

holes cannot be seen because of the hinged tin tops. Underneath each hole, how- 
ever, is the figure of a man. These figures are mechanically connected in series and 
can be made to appear on top of the table, being manipulated by the two uni- 
formed assistants who work the levers and tilt the tables.] 

First, let us ascertain the facts about Europe. The average popula- 
tion per square li is 13; Germany, 32; England, 40; Holland, 53; 
Belgium, 73. Turning to the yellow table, the average population 
for Asia is not 13 but 6; Japan, 28; India, 20; and China? According 
to a study of the Min Djen Bu Census and Custom's reports it is 11 
per square li. It is said that with the development of her natural 
resources and modern methods of transportation, irrigation, and 
river control, forestry, and agriculture, China can support a popula- 
tion three times as great as now. At the present time China ranks 
tenth in density of population among the great nations of the world. 

The Chain of Life in China 

To allow present dangerous health conditions to continue consti- 
tutes a real menace to China. It does make a real difference to a 
nation if it disregards the presence of such serious diseases as plague, 
smallpox, typhus, cholera, when other nations are rapidly making 
practical use of the methods which have been discovered for pre- 
venting or controlling them. The strength and safety of China may 
be very easily effected. 

[From the ceiling is suspended a long chain emerging from below a sky-blue cur- 
tain. The links are large, black, and strong. Opposite each link is written what this 
link stands for. Next to a huge box, painted a sickly white, is one link that is thin 
and partly broken. This is the present health link. The box represents the Chinese 
people. Nearby is a strong link waiting to be inserted to replace the weak health 
link. This is done by calling six men from the audience who hold up the big box 
while others change the link. The point is brought out that this change is possible 
only when all of the people understand what is going on and co-operate as far as 
possible. When the links are changed, an electric current is switched on and the 
powerful lights inside the box shine through the five-colored national flag.] 

The change will not be as rapidly effected as this. But once the 
change is made the whole aspect of the country will be different. 
Now we have a chain composed of these links: favorable location, 
national longevity, natural resources, great population, industry, 
frugality, and public health. 



EVENING ADDRESSES 107 

The Human Body 

In order to take proper measures for maintaining personal and 
national health it is necessary first of all to know something about 
the body in which we live. How many of you have ever seen a model 
of the human body? How many of you know the location and func- 
tions of the various parts? 

[There is brought in at this point a model of the body, life size, with removable 
parts which are explained in detail according to the nature of the audience. There 
follows a full statement as to the purpose and place of medical schools, nursing 
schools, hospitals, and the teaching of health habits in schools as well as general 
health education among the people.] 

The Largest Foundation Stone 

What is the foundation of national health? What are the com- 
ponent parts making for national health? 

[A glass box marked "National Health" is brought out and the audience is in- 
formed that once the important foundation stones are laid the box will light up. 
One by one the following stones are placed upon the platform; money, law, trained 
leadership, and finally public opinion. Upon placing them in pyramidal form upon 
the last mentioned, the top box becomes illuminated.] 

Individual Versus United Effort 

How is the foundation for national health to be achieved? The 
problem is so large and difficult. It will take so many years and so 
much effort that this is a very important question. 

[A large board 7 feet high is brought to the platform. Its face is covered with 
green wheels in front of which metal figures are seen turning their respective 
cranks. These wheels are marked to represent the five classes of Chinese society, — 
scholars, farmers, laborers, merchants, and soldiers. Each member of these classes 
has to work at his own task to gain a livelihood. But on the outer rim of the board 
is a large yellow wheel on which are marked the characters for national health and 
national strength. This wheel barely touches each of the smaller wheels inside. 
All those connected with the small wheels then work at their cranks. Some work 
this way and some that. No one pays any attention to the large wheel. This appa- 
ratus represents individual effort. 

A second board of the same size is placed beside the first. Here are the same 
classes but the people are touching elbows and working together. They not only 
move their own wheels but the larger one on the outside which is related to them 
all. This apparatus represents united effort. The two pieces of apparatus are 
worked for a few minutes and the audience is asked to decide which is the better 
way.] 



108 PEKING UNION MEDICAL COLLEGE 

China Tomorrow 

Would you like to see a picture of China tomorrow after you have 
done your share in making a contribution to the solution of the 
health problem of the nation? You saw a picture of China today, 
overburdened by a load of disease impeding every step of the way. 

[The curtains are drawn aside and a healthy Chinese is seen standing on the 
boxes marked plague, cholera, etc., which at the beginning of the lecture were in 
the bag slung around the neck of China. He holds the flag of China in his hand. 
On his back there is still a load of disease but it is smaller. The curtain is drawn.] 

Now having seen some of the fundamental facts relating to this 
question visualized before our eyes, let us get down to the prac- 
tical application in which we can all share now. The Chairman of 
the meeting will outline to you what you can do now for yourselves 
and for your own city. 

A program of activities carefully worked out beforehand is then 
presented and an appeal is made for every citizen to give the 
project his support. 

Before and after the public meetings the people are given an op- 
portunity to see a health exhibit which is explained by previously 
trained students who constitute a "health faculty." Literature is 
distributed and announcements are made of further meetings in the 
various parts of the city. 

SUMMARY 

A summary of our experience in these campaigns follows: 

i. Before modern health practices will be accepted by the 
Chinese people who do not understand them, general health educa- 
tion work is a primary necessity. 

i. Because the Chinese and foreign conceptions on health sub- 
jects differ so widely, special methods have to be devised to inter- 
pret modern health ideals to suit the Chinese mind. 

3. It has been found of some value to use three-dimension, mov- 
ing apparatus built on a large scale with each piece of apparatus 
designed to visualize one idea. In the demonstration of this appa- 
ratus use may be made to advantage of well-known citizens in the 
audience. 



EVENING ADDRESSES 109 

4. After a general presentation of some of the relations between 
national health and national strength, a practical program with its 
special appeal to the local community should be presented. 

5. Of permanent value in building up a better understanding of 
this subject are the large numbers enlisted in volunteer service and 
trained for leadership in this field. 



BIOCHEMISTRY IN RETROSPECT AND IN PROSPECT 

By 

A. B. Macallum, Sc.D., F.R.S. 

INTRODUCTION 

In selecting as the topic of my address this evening the subject of 
Biochemistry in Retrospect and in Prospect, I have been influenced 
by my experiences during the last twenty years in explaining to 
many inquiring persons the significance of the term " biochemistry." 
They are, of course, familiar with the terms chemistry, physics, 
geology, and astronomy, for these, after more than a century of use, 
are now, as it were, household words, but biochemistry is a word of 
much more recent origin and its connotation is consequently much 
less widely known even among those whose general information is 
very excellent. Since this science, as a new-comer in the field of 
organized knowledge, can make its way successfully only by receiv- 
ing the fullest support of those who are in a position to sway the 
opinion of the many, I think this is an occasion on which to pre- 
sent for general diffusion its significance, sketching briefly its his- 
tory and indicating what I believe it will accomplish in the future. 

This department of knowledge is known as biochemistry in the uni- 
versities of the British Empire, as biological chemistry in those of 
the United States, and as Biochemie in those of Middle Europe. The 
name Biochemie was coined by Hoppe-Seyler in 1876 but it did not 
obtain general acceptance in Germany until about twenty years ago 
and his own Chair in the University of Strassburg was known as 
that of Physiological Chemistry, a title that is still used for the few 
professorships of this science which have been created in the Ger- 
man Universities, in the majority of which biochemistry is taught 
under the auspices of physiology. 

BIOCHEMISTRY DEFINED: ITS RELATION TO OTHER SCIENCES 

Biochemistry, briefly defined, is the chemistry of living matter 
and of all its products, normal and pathological, which are of the 
class known as organic. These include cellulose in all its forms, 



EVENING ADDRESSES in 

cotton, and wood, the proteins which constitute silk, wool, and 
horn, and the products of tanning, but the scope of the subject 
as it is taught in universities is more limited. 

Because living matter and a great many of its important products 
are colloids it deals with colloidal chemistry, and since it is con- 
cerned with organic compounds and has to take account of the 
physical condition of solutions, it covers some of the fields of organic 
and physical chemistry and physics. Further, as it is specially con- 
cerned with living matter it cannot ignore the science of biology. 

EARLY RESEARCHES IN BIOCHEMISTRY 

The province of biochemistry is, therefore, a large one. Indeed the 
fact that it is so closely associated with other sciences accounts for 
its rather late appearance as a distinct science. Colloidal chemistry, 
though it harks back to the researches of Thomas Graham in the 
fifties of the last century, did not begin to develop as a science until 
about thirty years ago, and physical chemistry had its beginning in 
1887 with theories then advanced by Van't Hoff and Arrhenius on 
the nature of solutions. Biochemistry could not then have made 
great advances at a much earlier period even if its position as 
an independent or distinct science had been recognized. Further, 
certain great laws in the physical world had to be demonstrated as 
applicable also in the world of living matter. This demonstration 
involved difficulties which were only slowly overcome. The princi- 
ple of the Conservation of Matter, though proved for the physical 
world by Lavoisier in 1790, was established for the animal body by 
Liebig about the middle of the last century, while the principle of 
the Conservation of Energy, enunciated by J. R. Mayer in 1842 and 
proved by the researches of Joule and others later, was only finally 
demonstrated as applicable to the animal body by Rubner in 1894. 
Without such conquests it would have been impossible to have made 
any important advances over forty or fifty years ago. 

Nevertheless there were some notable conquests by chemists, 
physicists, and physiologists whose names should be remembered in 
the history of the science. This list includes Liebig, Wohler, Gobley, 
Mulder, Claude Bernard, Fick, Wislicenus, Thudichum, Lawes, 
Gilbert, and Voit. These names are unfortunately now passing from 



ii2 PEKING UNION MEDICAL COLLEGE 

the record but from 1820 to 1880 they were honored as those of 
great pioneers in the trackless unknown. They are rarely mentioned 
in the text books today and one wonders sometimes whether the 
future will spare enough thought to keep them from the oblivion 
that now engulfs the great pioneers of an earlier age. 

BIOCHEMISTRY DISTINGUISHED FROM CHEMISTRY AND PHYSIOLOGY 

The period from 1868 to 1885 marks the time when biochemistry 
began to assert a claim to the control of a province of knowledge 
distinct from chemistry and physiology. It was the time of Hoppe- 
Seyler, Miescher, Maly, and Schmiedeberg. Hoppe-Seyler was a 
leader in the field whose service in the development of the science 
will always be recognized. From 1868 to 1874 he published four 
volumes, entitled Medicinische-Chemische Untersuchungen, in which 
were detailed the results of a large number of important researches in 
medical chemistry. In 1876 he founded the Zeitschrijt jiir Physiolo- 
gische Chemie. He was one of the first of those appointed to the 
professorial staff of the University of Strassburg, reopened in 1872, 
and his Chair was that of Physiological Chemistry, the first of its 
kind established. His standing as a physiological chemist made that 
University a center for all the students of the time who aimed to 
undergo a training and to obtain a point of view which would fit 
them for a career in research in physiological chemistry. For a few 
years they were not many, as one may gather from the fact that 
among the contributors to the first eight volumes of the Zeitschrijt 
there were not more than eleven who had been students in his labo- 
ratory. The students of physiological chemistry elsewhere did not 
increase rapidly; in 1895, when Hoppe-Seyler died, the number of 
volumes of the Zeitschrijt had reached only twenty. 

Hoppe-Seyler vigorously asserted the claim that physiological 
chemistry was a science distinct from that of chemistry and from 
that of physiology. That claim was denied by the chemists and 
physiologists of the day, especially when the Zeitschrijt was founded. 
In some instances the opposition was marked. Pfliiger opposed the 
claim on the ground that its acceptance would do great harm to 
physiology. Many chemists were contemptuous. Hoppe-Seyler, 
however, persisted in his position and in the end won the desired 
recognition. 




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EVENING ADDRESSES 113 

DISCOVERY OF THE NUCLEINS 

Miescher, a student of exceptional ability and independent 
initiative, made his first appearance in research as the discoverer of 
the class of compounds known as nucleins, so called because the 
example of them which he isolated was derived from the nuclei of 
pus cells or dead white blood corpuscles. As we now know, nucleins 
are unique in that they contain nucleic acid which is a compound 
of phosphoric acid, a sugar of the pentose class and a purin or pyri- 
midin, the whole capable of uniting with a protein to form the com- 
plex nuclein which is the basis of the chief substance in the nuclei of 
cells and which is known to the cytologist as chromatin. The manu- 
script giving the results of his investigation Miescher offered in 1869 
to Hoppe-Seyler for publication in the Medicinische-Chemische Un- 
tersuchungen, but the latter, considering that the results detailed 
therein were of too remarkably novel a character to permit of their 
going on record without verification, held it for two years, during 
which he repeated some of Miescher's investigations, finally pub- 
lishing (in 1 871) the paper with an accompanying note to the effect 
that he had verified some of the most important of Miescher's ob- 
servations on the substance, nuclein, the discovery of which he re- 
garded as one of the most signal achievements for a decade in phys- 
iological chemistry. I cannot help wondering whether today there 
is an editor of a scientific archive who exercises a similar circum- 
spection in the selection of his material for publication, and also 
whether there has been evinced anywhere such an exhibition of the 
true scientific spirit. 

The discovery made by Altmann in 1886, that the nuclein mole- 
cule contains an integer, nucleic acid, a phosphoric acid ester of 
special constitution, added to the significance of Miescher's achieve- 
ment. 

Miescher continued in later years his researches on nucleins which 
now began to have a special importance because of the discovery by 
Alexander Fleming in 1878 of the phenomenal processes of cell 
division grouped now under the term karyokinesis or mitosis, which 
is concerned with the equal distribution between two cells, arising 
by division from one, of all the chromatin in the parent cell. It was 
soon recognized that this chromatin is the carrier of all the distinc- 



n 4 PEKING UNION MEDICAL COLLEGE 

tive characters of the parent organism to the offspring and conse- 
quently the nucleoprotein which constitutes it has a special signifi- 
cance, not only from the morphological but also from the chemical 
point of view. 

CYTOCHEMISTRY 

In 1 88 1 Langley had shown that the mother substance of some of 
the ferments, pepsin for example, could be localized in the cells of 
the peptic glands, and Heidenhain later demonstrated that zymo- 
gen granules exist in the pancreatic cells. These achievements, with 
the discovery and localization of nuclein in the cell may be regarded 
as constituting the beginning of the science of cytochemistry, a 
special and important line of biochemistry. They turned attention 
to the possibility of localizing in the cell, as seen under the micro- 
scope, some of its other products and contents, and in the eighties 
there were some who had hopes that the dawn of an era of great dis- 
covery in microchemistry had begun. It did indeed dawn but, al- 
though progress was made, the early light of that dawn is in great 
part still about us and the hope of a great achievement in micro- 
chemistry is still to be realized. The explanation for this postpone- 
ment is the inertia which in the long run chills enthusiasm, for "hope 
deferred maketh the heart sick." 

FURTHER LINES OF PROGRESS 

Before the close of the century progress along other lines began 
with an impetus which has not yet spent itself. This was prompted 
by the interest awakened by the theories which Van't Hoff and 
Arrhenius advanced in 1887 on the nature of solutions, which put a 
new aspect on questions of osmosis, of diffusion, and of the absorp- 
tion and secretion of inorganic solutes. 

These theories accounted for catalysis, including ferment action, 
diffusion, and osmotic pressure, and they led not a few to believe 
that many of the vital phenomena could be explained on the prin- 
ciples of physical chemistry. As a consequence a considerable num- 
ber of the younger generation of physical chemists entered as re- 
searchers the province of biochemistry in the two following decades, 
but although their contributions have been of value from their side 
of the subject it must now be recognized that physical chemistry, 



EVENING ADDRESSES 115 

as now defined, does not furnish solutions of many of the problems 
which confront the biochemist in his investigations of the phenom- 
ena of living matter, and it has been of comparatively minor 
service in explaining the processes by which living matter elaborates 
its products. 

THE COMPOSITION OF PROTEINS 

Perhaps the greatest stimulus to development which biochemistry 
received before the close of the nineteenth century was derived from 
the researches of Emil Fischer, on the composition of proteins, 
which were begun in 1893. The highest and most complicated prod- 
ucts of living matter are proteins which, in a colloidal condition, 
form the physical basis of life. In the seventies and eighties of the 
last century the constitution of proteins was practically unknown. 
On digestion a number of them were found to form peptones which 
because of their diffusibility were supposed to be absorbed as such 
and to be reconstituted into proteins in the body. The decomposi- 
tion of these peptones into simpler products, amino-acids, known as 
glycol, alanine, leucine, tyrosine, and one or two others, all of which 
had been isolated from the intestinal contents, was known in the 
seventies and eighties, but the significance of this was overlooked. 
It was even suggested that such products resulted from a wasteful 
decomposition in the intestine and that they were absorbed by the 
intestinal mucosa to undergo further wasteful decomposition in the 
body. 

The Amino- Acids. Fischer, by subjecting proteins to hydrolysis 
by acids, with the aid of heat, obtained solutions rich in the bodies 
known as amino-acids, including glycol, or amino-acetic acid, ala- 
nine, or amino-propionic acid, leucine, or amino-isocaproic acid, and 
tyrosine. Some of these he succeeded in separating from each other 
by converting them in the mixture into ethyl esters and distilling, 
each ester passing over as a distillate at its own temperature. Fisch- 
er's methods were followed by a number of workers and. through 
further improvements and the introduction of new and better 
methods the separation and estimation of the amino-acids which 
enter into the construction of the various proteins have progressed 
so far that we now know with an approximate degree of accuracy 



n6 PEKING UNION MEDICAL COLLEGE 

the amount of each amino-acid in each protein. Further, we now 
know that the fundamental integer in each protein is an amino- 
acid, or, to put it more simply, the building blocks of the structure 
of a protein molecule in the great majority of proteins are amino- 
acids alone, and that the particular properties of a protein are due 
to the variety and the amount of the particular amino-acids of which 
it is constituted. As there are nineteen amino-acids it is obvious that 
an extraordinary variety of proteins is possible. Further, Fischer 
determined that proteins are really chains of amino-acids, each 
amino-acid present contributing a link in the chain. 

How such chains can be constituted may be understood from the 
properties of a simple amino-acid like amino-acetic acid. This acid 
has the group NH 2 present in it and by virtue of its presence the 
acid has basic properties, that is, it can unite with an acid. It has 
also a carboxyl group, COOH, to which its acid properties are due, 
and it can consequently combine with a base to form a salt. Indeed 
the presence of both the amino and the carboxyl groups in the same 
molecule has suggested that they loosely unite with and thus partly 
neutralize one another and this, it is held, explains why amino-acetic 
acid is much less basic an acid than would theoretically be indi- 
cated by the presence of these groups. 

Fischer succeeded also in showing how the amino-acids are linked 
in the proteins. In this linkage the OH of the carboxyl groups of one 
molecule and one H of the NH 2 group of another are eliminated and 
there results the union of the two molecules so affected: 

NH 2 CH 2 -COOH+H 2 NCH 2 -COOH= 
NH 2 CH 2 -CO-NH-CH 2 -COOH+H 2 

As the product of this linkage has a carboxyl and an NH 2 group it 
can combine in the same way with two other molecules of amino- 
acids and the products, composed of four molecules of amino-acids, 
will, because of the presence of a carboxyl and an NH 2 group, com- 
bine similarly with two molecules of amino-acids. The process can 
thus be repeated almost ad infinitum, and theoretically the product 
might ultimately have so large a molecule that it could be seen with 
the naked eye and be picked up with a fine pair of forceps. Fischer 
succeeded by a tedious process in forming a polypeptide of eighteen 



EVENING ADDRESSES 117 

amino-acids. The cells of the animal body, on the other hand, have 
an extraordinary facility in the synthesis not only of polypeptides 
but of the highest and most complex proteins out of simple amino- 
acids, each organism, and perhaps each variety of cells constituting 
it, producing proteins of suitable types. It has also been established 
with some degree of certainty that the animal organism is not capa- 
ble of forming any of the amino-acids, with the exception of the 
simplest one of all the nineteen, namely amino-acetic acid, and in 
consequence proteins like gliadin, which occurs in wheat flour, zein, 
which occurs in maize, and gelatin, all of which lack one or more of 
the higher and more complex amino-acids, cannot, if they are the 
only proteins in a diet, sustain life. 

This work on the constitution of proteins has been paralleled by 
studies on the molecular structure of nucleins and nucleic acid. The 
results of these have indicated that the simplest nucleic acid mole- 
cule is a compound of phosphoric acid, a sugar either of the pentose 
or hexose class, and a purin or pyrimidin. The more complex nucleic 
acids are constituted out of the simplest acids, two, three, four, and 
perhaps more of the simplest uniting to form them. These nucleic 
acids have the property of uniting with proteins to form nucleins or 
nucleoproteins, a special variety of the latter constituting the all- 
important substance known to the histologist and cytologist as 
chromatin which, as already indicated, functions in the germ cells 
as the carrier to the offspring of the characters of the parent organ- 
isms. How it is constituted to function thus is as yet unknown but 
that is a problem the solution of which the future will undoubtedly 
bring. 

RECENT INCREASED ACTIVITY IN BIOCHEMICAL RESEARCH 

The work on the constitution of proteins as initiated by Emil 
Fischer and that of Kossel, Levene, and Walter Jones on nucleins 
and the investigations on the metabolism of proteins carried on from 
1893 to 1908 excited keen interest among the younger generation of 
workers in science and led to a great accession of recruits to the 
ranks of the biochemists. As a consequence, the literature of bio- 
chemistry, covering all departments of this science, has increased 
enormously during the last fifteen years. Much of this literature is 



u8 PEKING UNION MEDICAL COLLEGE 

to be found in the transactions of scientific academies and societies, 
but a not inconsiderable proportion of it has appeared in recently- 
established journals devoted to biochemistry alone. A few statistics 
gleaned from an examination of these will indicate what activity 
now prevails among the biochemists. The Biochemische Zeitschrift, 
which began its publication in 1906, has this year reached its hun- 
dred and fifteenth volume. The American Journal of Biological 
Chemistry, started in 1905, has already completed its forty-sixth 
volume. Hoppe-Seyler's Zeitschrift fur Physiologische Chemie, which 
began publication in 1876, and of which only twenty volumes had 
appeared in 1895, has this year reached its one hundred and twelfth. 
The total number of biochemical papers now annually published is 
very great. Early this year I endeavoured to determine the annual 
output by counting those listed for 1920 in the Centralbldtter and in 
other journals for abstracting, and, as a result, arrived at the esti- 
mate of nearly four thousand for that year. This estimate I believe 
to be a conservative one. A large number of papers on biochemical 
subjects which have appeared in the medical journals and the 
publications of scientific societies are not included because a census 
of such journals and publications was, I found, too great a task. 

All this activity is in marked contrast to that which existed in 
biochemistry forty years ago. The number of biochemical papers 
published in 1880 did not exceed one hundred and twenty; there 
was then only one journal devoted to their publication, of which 
one volume appeared annually. There were indeed other papers 
which touched on biochemical subjects, or contained the results of 
some investigations bearing on physiological or pharmacological 
problems which bore also on biochemical topics, but if these were 
counted one would also have to include similar papers in the esti- 
mate for 1920 and it would thereby have to be considerably in- 
creased. 

Biochemistry has, therefore, very greatly developed since 1880 
and it is, in consequence, asserting today a claim for recognition as 
a science of the first rank and promises supreme service in the solu- 
tion of many problems which are of outstanding importance. 

Its recognition as an independent department of activity is al- 
ready conceded among men of science generally. The definiteness 



EVENING ADDRESSES 119 

of its knowledge after forty years of research and the value of that 
knowledge, not only to medicine but also to pure science, have been 
responsible for allaying opposition and silencing criticism on the 
part of chemists and physiologists of thirty to forty-five years ago. 
The only criticism that one hears today bears on the training that 
not a few biochemists have undergone, a training which, it is claimed, 
is one-sided or insufficient to qualify them for attacking the prob- 
lems that have engaged their attention. This criticism is to a certain 
extent justified, but I may, however, state that the same criticism 
may be urged in the case of every science today, for there is in the 
ranks of chemists, physicists, geologists, biologists, and physiologists 
as large a proportion of inadequately trained workers as there is 
in the ranks of biochemists. 

The past of biochemistry, because of the value of its achievements, 
is secure. Its future is to be one of still greater achievement. Indeed, 
it is certain that the activity in biochemical research will be greatly 
enhanced as the years go by, for the problems for investigation be- 
come more accessible and easier to attack with the increase of 
knowledge which the researches of each year bring. Further, the 
future training of biochemists for research will cover a far wider 
field than that which the present and the past generations underwent. 
This will enable our successors to obtain results where we have 
failed and to open up new lines of investigation, the results of which 
may lead to recasting our points of view on a number of subjects 
now apparently incapable of change. We have had an experience of 
such recasting in connection with the researches on "vitamines. " 
Although the existence of such important substances was indicated 
by the researches of Lunin, in 1880, nothing came of his observa- 
tions, and twenty years ago no one would have suspected that a 
diet of pure proteids, fats, and carbohydrates would fail to meet the 
requirements of normal nutrition. It was only in 1906 that the 
existence of these "vitamines," or "accessory food factors," was 
again indicated by the results of researches carried on by Gowland 
Hopkins. In the intervening fifteen years a knowledge of these sub- 
stances has developed, in consequence of which they are now recog- 
nized as playing an all-important part in directing the course of 
nutrition — a fact that no one even suspected thirty years ago. 



120 PEKING UNION MEDICAL COLLEGE 

THE FUTURE OF BIOCHEMISTRY 

Along what lines will biochemistry develop in the coming years ? 
To answer this question with accuracy requires a prophetic vision 
which is granted to very few, and, therefore, I shall not presume to 
speak with any more certainty than is justifiable in one who has 
been a student in this line for the last thirty-five years and who has 
watched, expectantly, the progress of the science during all that 
time. I am confident that, in the main, its developments during the 
next thirty years will take place along the lines which I will now 
attempt to indicate. 

LINES OF FUTURE RESEARCH 

General Nutrition. The subjects of the research of today are cer- 
tain to continue to be the subjects of patient and exhaustive re- 
search for four or five decades more. Among these problems are 
those involving general nutrition in health and disease. The disor- 
ders of nutrition are determining factors in a large number of dis- 
eases, and to control these factors more knowledge is necessary which 
can be obtained only by prolonged research on metabolism in health 
and disease. Our knowledge of the proteins, great as it is and due to 
the enthusiasm of the biochemists of the last twenty-five years, is still 
wanting on many important points. Our knowledge of the fate of 
the amino-acids resulting from digestion and absorbed by the in- 
testinal mucosa is very incomplete and our conception of the nature 
of the transformations of the proteins which take place inside the 
body is exceedingly exiguous. Our knowledge, also, of the composi- 
tion and mode of action of the various enzymes of the animal 
organism, especially those which are concerned in tissue metabo- 
lism, is very nebulous. We shall be able to obtain a full understand- 
ing of all such fundamental chemical changes in the various tissues 
and organs only through many and prolonged investigations. 

Metabolism of Fats and Carbohydrates. A very great amount of re- 
search is still needed regarding the metabolism of fats and carbohy- 
drates. We are yet in the dark as to the manner in which they are 
broken down in the tissues. The magnitude of our lack of knowl- 
edge may be illustrated by reference to the current explanation of 
the causation of diabetes mellitus. This disease has been, and still 



EVENING ADDRESSES 121 

is, held to be due to a loss of power on the part of the tissues of the 
body to utilize the sugar which is accessible to them. It is now be- 
coming clear that there is in this disease a certain loss of power to 
break down fats, which shows itself in about 65 per cent of the dia- 
betic patients of adult life by a more or less extreme adiposis and 
also in the production of aceto-acetic acid, (3-oxybutyric acid, and 
acetone, which appear in the urine at critical stages and which un- 
doubtedly arise from failure in the oxidation processes concerned in 
the final products of fat metabolism. There is still much research to 
be done on carbohydrate and fat metabolism before we can obtain 
a satisfactory explanation of the causation of even this one disease. 

I'be Vitamines. The vitamines are today of surpassing interest in 
the biochemical world. The investigations of the last ten years have 
shown that these substances are indispensable in a diet which is to 
promote normal growth and maintain a normal nutrition. This is 
emphasized by the many thousands of cases of rickets among the 
children of Vienna at the close of the war, caused by the absence for 
two years of the fat soluble factors from their diet. The importance 
of the vitamines is also indicated by the prevalence of beri-beri 
during the last thirty years in Java, India, Japan, and in certain parts 
of China, the occurrence of scurvy from time to time during the last 
fifteen hundred years, and the incidence of pellagra in the southern 
parts of the United States, in Italy, Spain, and Egypt. 

The full significance of the effects of the absence of vitamines 
from a diet has not been fully determined. McCarrison's observa- 
tions on the results of feeding animals with vitamine-free food make 
one suspect that their action on the tissues of the body is more pro- 
found than the results of previous researches have indicated. The 
sloughing of the intestinal epithelium in his animals, but more es- 
pecially the hypertrophy of the medulla of the suprarenal gland is, 
in my opinion, extremely significant. I am led to suggest that 
vitamines play a part in the animal body parallel in many respects 
to that of the internal secretions, although they are formed only in 
vegetable organisms. Are they internal secretions, the capacity to 
form which has been lost by the animal organism? 

Their chemical constitution has still to be determined. The re- 
searches carried out on them have so far left their composition un- 



122 PEKING UNION MEDICAL COLLEGE 

determined. It is unbelievable that during the next ten years their 
chemical character will remain unrevealed; and it will fall to the lot 
of some biochemist to isolate one of them, very probably the anti- 
neuritic (water-soluble B) in a pure form and ascertain its com- 
position. There should then follow its synthesis in the laboratory 
and the exact determination of its action in the body. 

The Internal Secretions. Our knowledge of the internal secretions 
is still only fragmentary. We have definitely ascertained the chemi- 
cal composition of that of the suprarenal gland, and it is possible 
that the compound thyroxin isolated from the thyroid gland by 
Kendall, may be the fundamental secretion of the gland, but we 
have no knowledge of the chemical characters of the internal secre- 
tions of the parathyroids, the thymus, the pituitiary, and pineal 
glands, or of the interstitial cells of the testes and ovaries. We are 
also wholly in the dark as to the character of the internal secretion 
or secretions of the pancreas that are concerned with carbohydrate 
metabolism, the absence of which leads to glycosuria or diabetes 
mellitus. Here is a field in which for the next two or three decades 
the activity of biochemists associated with physiologists may result 
in a lore that will enable us to control exophthalmic goitre, in- 
fantilism, acromegaly, diabetes mellitus, and other disorders due 
to the failure in activity, or to the hyperactivity of the endocrinous 
organs. 

The Chemistry of Immunity. The chemistry of immunity to in- 
fectious diseases is today almost an unknown subject. The chemis- 
try of bacteria has not been determined, largely because it is difficult 
or almost impossible to obtain a sufficient quantity of any one 
bacterial form to serve for such an investigation. The chemical 
characters of the substances which diffuse from them have not been 
ascertained and, in consequence, we know little or nothing of the 
mode of production of the antitoxins. The substances which can act 
as antigens are apparently of the protein class alone and therefore 
the antibodies produced by the antigens must be proteins. Their 
nature is, however, obscure or very indefinite; for, as Huntoon, 
Masucci, and Hannum have found, these antibodies, or antitoxins, 
or precipitins, do not undergo digestion with trypsin, and conse- 
quently, if they are composed of proteins, as they probably are, 



EVENING ADDRESSES 123 

these cannot be of the serum or of the tissue class. The character of 
the compounds that are responsible for the anaphylactic reaction is 
as yet a matter of surmise only, and therefore much remains to be 
ascertained in regard to them. The chemistry of immunology is a 
virgin field, awaiting the investigations of tireless and enthusiastic 
biochemists in the next few years. It is not too much to expect that 
in this line advances will be made which will add greatly to our 
armamentarium against infectious diseases. 

The Chemistry of the Intestinal Mucosa and the Microchemistry 
of the Cell. Among the lines of investigation which will inevitably 
be pursued in the next few years and which I believe will yield 
results of transcendent importance will be those concerned with the 
chemistry of the intestinal mucosa and the microchemistry of the 
cell. The intestinal mucosa is one of the great gateways of the 
body to disease. It is constantly exposed to the action of prod- 
ucts of bacterial fermentation, and when these are toxic the epi- 
thelial cells are the first to experience their action. In fact there 
are no other cells of the body which are subject to such an extreme 
variety of conditions and to such a constantly changing environ- 
ment as are the epithelial cells of the intestinal mucosa. They un- 
doubtedly react to a number of these conditions, neutralizing the 
toxic products and thus constituting the first line of defense of the 
organism against disease. When they fail to act in this capacity, 
disease consistent with its origin begins in one or more of the organs. 
I am strongly of the opinion that, for example, hepatic cirrhosis, 
several kinds of nephritis, arterio-sclerosis, angina pectoris, senile 
dementia, and dementia precox are due in part to alterations in the 
capacity of the epithelial cells of the intestine to perform their 
normal functions. 

What changes the epithelial cells undergo to permit the develop- 
ment of the diseases mentioned we do not know. But we know very 
little regarding the activities of these cells. 

The microchemistry of the cell, the other great line of advance in 
the near future, will involve an interest wider than that of medicine. 
The cell is the physical basis of life and consequently a profound 
knowledge of its composition, of the chemical processes that con- 
stantly occur in it, and especially of the physical forces that govern 



1 24 PEKING UNION MEDICAL COLLEGE 

it, would give us not only a deeper insight into the phenomena of 
disease but also some slight understanding of that great enigma, 
life itself. I have already indicated how little we know of the chem- 
istry of the cell. Our knowledge of the physical forces is very much 
more scanty, in part because it is only recently that attention has 
been directed to them, but mainly because the working of some of 
these forces, even in the purely physical world, has not been fully 
investigated. This is especially the case with surface energy, which 
seems to play a dominant part in cell life. In association with an- 
other physical force, intrinsic pressure, it appears to control the 
absorptive, secretory, and excretory activities of the cell and there 
are some facts which seem to indicate that it is concerned in the 
most fundamental functions of nerve cells, such as the production 
and transmission of nerve impulses, in perception, sensation, and 
possibly memory and thought. This would postulate that the phys- 
ical basis of psychic life is the co-ordinated surface energy of the 
millions of nerve cells in the cerebral cortex, the surface energy that 
is of the same character as that which determines the shape of a 
drop of water, the surface of molten planets, the sun, and the far- 
distant gigantic Arcturus. How the entity that is known as the Ego 
functions in this surface system of the nerve cells must remain a 
mystery. 

It follows that the microchemistry of the cell involves profound 
philosophical problems as well as those of purely scientific interest. 
In researches along this line one comes into contact with questions 
which have formed the subjects of speculations ever since men began 
to attempt to solve the riddles of thought and being. Because it 
supplies a new approach to the solution of some of these the micro- 
chemistry of the cell will prove a lodestar to research in the coming 
years. 

CONCLUSION 

Biochemistry, therefore, because of its achievements in the past 
forty years and of its promise of achievements in the future, must be 
regarded as a development of knowledge of the first order of im- 
portance not only to scientific medicine but also to philosophic 
thought, even in its most esoteric form. During the next generation, 
biochemistry, associated with physiology and pharmacology, will 



EVENING ADDRESSES 125 

help to realize the hope that medicine will discard the last traces of 
that empiricism which has so long impeded its progress. 

It is my earnest hope that here in China research in biochemistry 
will be generously encouraged and that in this great School of Medi- 
cine will be trained biochemists who will play an important part in 
fostering research in the various universities and medical schools in 
China, both those now existing and those certain to be founded in 
the coming years. There is, I am convinced, as much capacity for 
research in the young Chinese students as there is in the students of 
science of the Western World, and it needs only steady encourage- 
ment to develop that capacity to the fullest degree. If that encour- 
agement is given and the expected results follow, this School of 
Medicine will have achieved one of its greatest functions. 

Before closing I would pay my tribute to all those who have been 
concerned in the foundation of this School of Medicine. It is a 
magnificent achievement and it is certain to play a splendid part in 
the development of scientific medicine in China. This School is des- 
tined to be a great center not only for medical education but also 
for research, the constant prosecution of which will be a powerful 
force in combating the traditional ideas regarding medicine which 
exercise such an unfortunate influence on the minds of the people of 
this country. It is already a beacon light of hope to those Chinese 
who are longing for help to ameliorate the lot of the suffering among 
the swarming millions who are now, as in the past, subject, on an 
appalling scale, to the ebb and flow of misery, to famines almost 
countless in number, and to an incidence of disease without a parallel 
anywhere else on the globe. There is and will continue to be much 
sordidness in the world — we have seen much in the late war which 
would seem to deny hope to those who dream of the coming of a day 
when savagery will be washed out of the human mind — and there 
is, in consequence, a lessened optimism in all who work for progress. 
To find, however, here and there forces such as those which this great 
School will exercise, is to make us lift up our hearts in gratitude. 
And that gratitude will not die with us; in the far-distant years 
those who have striven nobly to serve their fellow-men will be re- 
membered, and those who have made the establishment of this 
great School possible will be held in an abiding memory. 



THE SEARCH FOR THE IDEAL IN HOSPITAL 
ORGANIZATION 

By 

S. S. GOLDWATER, M.D. 

Sir Thomas More, the celebrated statesman and author, who 
added so much luster to the reign of Henry VIII, was struck by the 
fact that there was something about the hospitals of England in the 
early part of the sixteenth century that made men shun them, and 
in his famous Utopia he set forth the characteristics of an ideal 
hospital in a manner which has not been surpassed by any writer on 
hospitals, lay or professional, in the four hundred years that have 
since elapsed. In the perfect state which More's fertile imagination 
evoked, the people had a tender regard for their sick: "They take 
more care of their sick than of any others; these are lodged and pro- 
vided for in public hospitals. They have belonging to every town 
four hospitals, that are built without their walls, and are so large 
that they may pass for little towns; by this means, if they had ever 
such a number of sick persons, they could lodge them conveniently, 
and at such a distance that such of them as are sick of infectious 
diseases may be kept so far from the rest that there can be no dan- 
ger of contagion. The hospitals are furnished and stored with all 
things that are convenient for the ease and recovery of the sick; and 
those that are put in them are looked after with such tender and 
watchful care, and are so constantly attended by their skillful phy- 
sicians, that as none of them is sent to them against their will, so 
there is scarce one in a whole town that, if he should fall ill, would 
not choose rather to go thither than lie sick at home." 

With the best of good-will concentrated on hospitals in countries 
the most advanced in the arts of civilization, it has taken centuries 
of unflagging effort to lift hospitals to a position of safety and 
desirability. It was still a question sixty years ago whether the es- 
tablishment of a hospital in such countries as England and France 
was an event fraught with good or evil, and hence we find Florence 
Nightingale beginning the preface of the third edition of her Notes 

lib 



EVENING ADDRESSES 127 

on Hospitals, published in 1863, with these words: "It may seem a 
strange principle to enumerate as the very first requirement in a 
hospital that it should do the sick no harm. It is quite necessary, 
nevertheless, to lay down such a principle because the actual mortal- 
ity in hospitals, especially in those of large crowded cities, is very 
much higher than any calculation founded on the mortality of the 
same class of diseases among patients treated out of hospitals would 
lead us to expect." 

If we may assume that hospital conditions in the United States 
during this period were not materially different from those prevail- 
ing in England, evidence of progress during the thirty years follow- 
ing the publication of Florence Nightingale's book may be found in 
the transactions of the National Congress of Charities, held in 
Chicago in 1895; for it was upon that occasion that Richard Wood, 
a Trustee of the Hospital of the University of Pennsylvania, re- 
marked that there was still "among the uninstructed, a horror of 
the hospital," which Mr. Wood attributed to the fact that "the 
ignorant imagine the sick to be at the risk of untried remedies, and 
to be the subject of experiment, because poor and treated freely." 
But to Mr. Wood himself, and to the social and intellectual class to 
which he belonged, the hospital in 1895 had ceased to be a thing of 
terror, and had become " a tree of life, the leaves whereof are for the 
healing of nations." 

In our own day the good accomplished by hospitals is not a sub- 
ject of dispute; nevertheless, the precise place that the hospital 
should occupy in the body politic, the proper seat of responsibility 
for its existence and for its work, and the principles of its organiza- 
tion and administration remain fruitful subjects of investigation 
and debate. As an introduction to the consideration of means by 
which the usefulness of hospitals may be enhanced, let us review 
briefly some of the principal administrative objectives of recent 
times. 

MODERN ADMINISTRATIVE IDEAS 

About twenty years ago there sprang up in the United States an 
association of hospital superintendents, the first organization in the 
Western Hemisphere of men whose efforts were devoted to the im- 
provement of hospital conditions. The declared object of the Asso- 



ia8 PEKING UNION MEDICAL COLLEGE 

ciation was the promotion of economy and efficiency in hospital 
administration. A review of the earlier transactions of this associa- 
tion shows that the hospital superintendents of America were at 
that time concerned chiefly with the care of buildings and the eco- 
nomical purchase and distribution of supplies. Hospital manage- 
ment was by them conceived to be scarcely more than a form of 
household administration. 

How strikingly this point of view contrasts with that of the pro- 
gressive superintendent of the present day, who, without relinquish- 
ing his interest in the problems of internal institutional management, 
is concerned lest the hospital fail to measure up to the health needs 
of the community! To define the relation of the hospital to the com- 
munity is today accepted as the essential theoretical problem of 
hospital administration; to fit the organization of the hospital for 
the performance of its duties as thus defined, as its fundamental 
practical problem. 

If the symptomatic treatment of disease in the individual no 
longer satisfies the scientific clinician, the mere sheltering of the 
sick in order that such treatment may be administered no longer 
satisfies the thoughtful hospital administrator, who seeks to bring 
organized medical practice under the influence of the latest and 
most approved scientific conceptions of disease. The path of scien- 
tific medicine proceeds through the several branches of pathology 
to causation and prevention, and it is along this path that organized 
medicine, represented chiefly by the hospital, is advancing. Numer- 
ous surveys undertaken by American communities in recent years 
clearly indicate this trend. The object of such surveys is to deter- 
mine the character and the incidence of existing disease, and to dis- 
close relevant environmental factors, and on this broad basis to de- 
fine hospital functions and to formulate hospital programs. The 
logical result can be nothing less than an attempt to levy upon and 
skilfully to organize all available resources of society for the preven- 
tion and cure of disease. 

That in one of its aspects hospital administration is a branch of 
domestic administration need not be denied, but orderly household 
arrangement is today regarded as the least of hospital problems. 
The hospital has become conscious of its duty as a center for medi- 



EVENING ADDRESSES ia 9 

cal research in preventive as well as in clinical medicine, as an in- 
strument for the training of physicians and nurses, as a school where 
the laws of health may be imparted to the laity, and even as an 
avenue by which statesmen may be led to perceive the danger of 
any social or industrial system which disregards the health of the 
people. 

John Morley in his Life of Voltaire tells of Voltaire's youthful 
intellectual limitations under the narrowing influence of social life 
at the court of France; he describes Voltaire's escape into England 
and indicates the enlightenment which resulted from Voltaire's 
challenging and stimulating contact with a free people and their 
institutions. When Voltaire returned to France, says Morley, he 
"had tasted of the fruit of the tree of scientific reasoning and had 
become alive to the central idea of the social destination of all art 
and of all knowledge." Intellectual and social influences no less 
potent than those which influenced Voltaire's later career have re- 
cently been at work to widen the horizon of the hospital adminis- 
trator and to reveal to him the social character and destination of 
the institution over which he presides. 



TYPES OF MODERN HOSPITALS 



The three great types of hospitals in the modern world are the 
public hospital, managed by public officials and supported wholly 
by public funds; the private, non-sectarian hospital; and the secta- 
rian hospital, likewise under private control. Each of these types has 
distinctive characteristics, but all reflect in greater or less degree 
the scientific, social, and economic standards of the period. 

The private or voluntary hospital, upon which the people of Eng- 
land pride themselves as peculiarly an English institution, is dom- 
inated by the belief that bureaucracy, with all that the term implies 
of the inflexible and unpitying application of rules, lack of initiative, 
and loss of spontaneity, is the worst of all possible influences in a 
humane institution, and the last of all possible forms of control 
which should be tolerated by free men. The English system, trans- 
planted in America and in the British Colonies, has flowered vigor- 
ously, but neither in the overseas dominions of Britain nor in the 
United States has there been such uncompromising insistence as in 



10 



130 PEKING UNION MEDICAL COLLEGE 

England on absolute freedom from all subordination to or official 
relationship with government authority. 

Generously supported by voluntary contributions, while neigh- 
boring rate-supported or state hospitals were receiving insufficient 
doles from the public treasury; free to experiment with both con- 
struction and organization, while public hospitals were fettered by 
official restrictions; so situated as to be able to take a leading part in 
medical and nursing education; giving generously to the poor and 
deservedly applauded as an expression of the more kindly qualities 
of the Anglo-Saxon race; limited in size and therefore free from the 
evils of machine-like administration which cling so tenaciously to 
great institutions, the voluntary hospitals of England were long 
regarded as the supreme charitable effort of modern society at its 
best. Nevertheless, the English voluntary hospitals, compared with 
voluntary hospitals in other parts of the English-speaking world, 
have seemed to some to be mistaken in their refusal to utilize any 
of their facilities for the treatment of the well-to-do, as well as in 
their uncompromising determination to steer clear of official con- 
trol. The traditional English policy has apparently delayed the day 
of hospital co-ordination, without which a comprehensive com- 
munity program for the conservation of health cannot be achieved. 
Just now some of the hospitals of England seem disposed to reshape 
their program so as to provide service for social classes heretofore 
excluded from their benefits. A drift of policy is likewise discernible 
in the direction of partial state support. 

In the United States voluntary hospitals have been widely devel- 
oped along sectarian lines. The religious instinct, often suppressed 
under the stress of modern economic life, is apt to reassert itself 
when illness appears. The sufferer who is racked in body and mind 
finds peace most readily among fellow-believers. Eager to render 
service, the churches of America have vied with each other in the 
endowment of sectarian hospitals where service is offered alike to 
rich and poor, and where tender nursing care and a sympathetic 
religious atmosphere are regarded as of greater worth than mere 
efficient business organization or even, may I say, than accuracy in 
diagnosis. 

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EVENING ADDRESSES 131 

ideals of freedom, sympathy, and religion determine to a great ex- 
tent the general character of the hospital, and fix the nature of the 
controlling authority; but there are countries where these motives 
do not freely operate, sometimes because the underlying human in- 
stinct is not sufficiently developed, sometimes because means are 
lacking, and again on account of political conditions. In the latter 
connection, one thinks of continental European countries where 
organized medical service, originally almost wholly an affair of the 
church, has become an accepted function of the state. Even in those 
parts of the world where the voluntary hospital, sectarian and non- 
sectarian, has flowered most luxuriantly, the insufficiency of avail- 
able private funds, the tendency of voluntary hospitals to focus 
their attention on certain classes of the sick to the exclusion of 
others equally deserving, and the imperious demands of social 
hygiene, have caused the state to set up public hospitals for the 
purpose of filling gaps in the voluntary system. 

There are two respects in which the state hospital occupies a 
position entirely distinct from that of the voluntary hospital; the 
first is its acceptance of the responsibility of society as a whole (in 
contradistinction to that of sectarian or other groups) for medical 
relief; the second is its support, at least potentially, by all the re- 
sources of the state. There is no limit to the share of its wealth that 
the state may devote to the protection of the health of its citizens, 
and there is no social or invalid class which may logically be ex- 
cluded from the benefits of a state medical service, once instituted. 
The principle of state responsibility for the care of the sick having 
once been accepted, the extent of its application becomes simply a 
question of expediency. In its narrowest application, state medical 
service is limited to the care of persons suffering from communicable 
disease, and here the dominant motive is the protection of society, 
rather than the care of the sick; in its widest application, it includes 
not only every useful variety of hospital, but, reaching out beyond 
the walls of the hospital, it seeks to provide medical treatment in 
the school, in the workshop, and wherever such treatment may be 
required, even to the extent of providing constant oversight of the 
health of citizens, in all the circumstances of life, from infancy to 
old age. 



132 PEKING UNION MEDICAL COLLEGE 

DEVELOPMENT OF CLINICAL ORGANIZATION 

While the progress of a hospital toward efficiency may be accel- 
erated or retarded by its status as a public or a private institution, 
social, scientific, and economic forces play upon all types of hospitals 
without regard to their official relations. Perhaps the greatest single 
factor in modern hospital development has been the specialization 
of labor, a process which may be observed both in the medical 
branches and in general hospital administration. The intensive 
cultivation of limited areas of thought and action is a phenomenon 
characteristic of our age. It has left its impress on all the sciences 
and on most of the arts, but in medicine its first strong impulse has 
now been expended, and the period of differentiation, which tended to 
separate medical practitioners into many classes, has been followed 
by an irresistible demand for the co-ordination of the efforts of the 
different types of practitioners. Thus we have arrived at so-called 
"group medicine." 

In the earlier days of specialization, specialists in New York and 
elsewhere sought to acquire the facilities necessary for the free de- 
velopment of their art through the establishment of independent 
hospitals of limited scope. They were forced to do this by the refusal 
of the departments of general medicine and surgery to yield ground 
to them. For a time the internist and the general surgeon were able 
to maintain their opposition to clinical innovations. But the spe- 
cialists working in hospitals of their own, outside of the general hos- 
pitals, progressed rapidly in the development of an invaluable diag- 
nostic and therapeutic technique, and it was not long before the 
need of their services began to be felt in the general hospitals; at 
this time consulting specialists were added to the regular hospital 
staffs. These consultants were at first simply called in occasionally 
to assist in diagnosis and treatment, but in the course of time the 
hospitals perceived the advisability of providing separate wards to- 
gether with suitably equipped treatment rooms and laboratories 
for the special clinical branches; and thus the departmentalized 
hospital emerged. The change that we have just outlined was 
most quickly effected in hospitals which were affiliated with 
medical schools, for it was in such institutions that the need of 
varied and comprehensive clinical facilities was first experienced. 



EVENING ADDRESSES 133 

One of the things that stimulated the development of hospitals 
made up of a number of medical departments, combined and co- 
ordinated in such a manner as to permit of concerted clinical 
effort, was a growing appreciation of the fact that, indispensable 
as may be the specialist's contribution to the welfare of the hospital 
patient, it is prudent not to regard this service as self-sufficient or 
final, but wise rather to estimate it as a link in the chain of co-op- 
erative clinical relief. The time is rapidly approaching when spe- 
cialists will not be willing to treat most of their patients unaided, and 
when public opinion will decline to sanction such treatment, even if 
the specialists be willing. 

Disregarding for the moment the personal equation and consider- 
ing merely the question of method, one may today with reasonable 
accuracy appraise the clinical proficiency of a hospital by ascertain- 
ing the number of separate departments which contribute to the 
diagnosis and treatment of the average clinical case. If it is not al- 
ways true that sound practice prevails where team work flourishes, 
at least we may say that the opportunities for effective medical 
work are greatest where team work is highly prized. Broadly speak- 
ing, then, it may be said that a notable advance has been made 
toward hospital efficiency, first, by the training of special types of 
practitioners, and then by the co-ordination of the activities of the 
several skilled groups. 

LABORATORY DEVELOPMENT 

While the clinical development of the hospital was proceeding 
along these lines, laboratory medicine was following a parallel route. 
The single pathologist who, thirty or forty years ago, was able with- 
out an effort to satisfy all of the scientific demands of his clinical 
associates, has been replaced by a numerous laboratory staff, each 
member of which finds plenty of work to do in his chosen specialty, 
whether it be tissue pathology, bacteriology, pharmacology, serol- 
ogy, radiology, or cardiology, but in this field also the attempt to 
achieve perfection by intensive specialization has been followed by 
a growing appreciation of the dangers of isolation, and by a demand 
for a close working arrangement between the laboratory and clin- 
ical groups. 



i 34 PEKING UNION MEDICAL COLLEGE 

The successive phases of laboratory development are reflected by 
the manner in which hospitals have planned and erected their 
laboratories. An historical study of hospital plans tells the whole 
story. Beginning in 1870, when hospitals were frequently planned 
without laboratories of any kind, one finds in succession the follow- 
ing laboratory types: a single, rather small room; a small pathologi- 
cal laboratory combined with the morgue; a larger laboratory, 
equipped for pathology and bacteriology, still combined with the 
morgue; suites of rooms in the arrangement of which chemistry 
finds a well-recognized place, but which, despite a growing intimacy 
with the clinical departments, continue to be located in basements 
or in other remote places; differentiation of the general from the 
clinical laboratory, the latter becoming an important annex to the 
ward; and finally, a stage in which the intimate collaboration of the 
laboratory and clinical divisions of the hospital is recognized and 
promoted by the grouping of the wards and the out-patient depart- 
ment about a central building, which contains all that the hospital 
is able to afford in the way of specialized diagnostic and therapeutic 
equipment. 

CONDITIONS OF PROGRESS 

About thirty years ago, a feeling of restlessness swept over the 
hospitals of the United States and Canada. Under the leadership of 
a few men of genius, magnificent work was being accomplished in 
one or two centers, and a standard of achievement was thus set up 
which stirred others to action, prompting widespread reorganiza- 
tion. But how to proceed was a problem; for, in many instances, 
when a new scheme of organization was proposed, it became appar- 
ent that the key positions in the clinical organization of the hos- 
pital were held by men not abreast of the times, and that no matter 
how the organization might be changed on paper, the result was 
likely to be the reinstatement of some of these influential men in 
positions directly athwart the path of progress. In this situation the 
conviction grew that youth with its modern training would save the 
day, and, in order to create positions for young men of promise, a 
plan was widely adopted for the automatic retirement of the incum- 
bents of clinical positions upon reaching a certain age, or upon the 
completion of a definite term of service. America was at least thirty 



EVENING ADDRESSES 135 

years behind England in resorting to this expedient. French sym- 
pathy with the idea that men of mature years involuntarily impede 
progress is somewhat touchingly expressed by Duclaux who, re- 
counting in his study of Pasteur the difficulty experienced in obtain- 
ing a hearing among medical practitioners for advanced biological 
conceptions, says: "Physicians are those I would wish to lay hold 
of, and I begin to fear that I shall not succeed. I know very well that 
old physicians do not read any more, and that when they do read, 
do not understand." Although, here and there, a useful hospital 
career has perhaps been cut short by the policy of systematically re- 
placing older with younger men, the net result has doubtless been 
advantageous to progress; but so simple a rule of procedure does not 
and cannot of itself invariably bring about an ideal hospital organ- 
ization. Let one clinician be replaced by another, and if both have 
the same outlook on life, even though one be old and the other 
young, the same stagnation will result. How to insure perpetual 
progress is the problem. 

Is the problem automatically solved when teaching is introduced? 
Is teaching the magic word? I need but recapitulate the familiar 
arguments in its favor. To the teacher, surrounded by the eager and 
inquiring minds of youthful students, is given a sure and constant 
incentive to discover and rediscover truth. The mind of the teacher 
is perpetually refreshed. The conscientious and well-endowed teacher 
can hardly fail to become observer, thinker, questioner, leader. To 
him is given the opportunity, through his influence upon the minds 
of his students, to project himself indefinitely into the future. In the 
atmosphere of the school, research is born, and research is the key 
to the hidden secrets of nature. Thus the greater usefulness of the 
teaching hospital is apparent. But all teaching hospitals are not 
alike in their organization; standards are lacking, and appear to be 
needed. We arrive then at the question of hospital standardization. 

HOSPITAL STANDARDIZATION 

Can a type of organization, a method of hospital administration, 
be prescribed which is suitable for all places and all times? It may 
be useful to formulate the principles of hospital function and organ- 
ization, but to define in exact terms the character of the organiza- 



136 PEKING UNION MEDICAL COLLEGE 

tion, and to limit the activities of the hospital within the terms of 
the definition, is to obstruct progress. Standardization so conceived 
is a more pernicious influence than state control or bureaucracy, for 
a bureaucrat may change his mind, while the written word is inflex- 
ible. Nevertheless standardization becomes a useful instrument 
when understood simply as a means of upholding minimum 
standards. 

The standardization of hospital work is no novelty. Standards 
exist wherever the state through legislation has defined the condi- 
tions under which medicine or nursing may be practiced in a hos- 
pital. The formation of voluntary organizations for the promotion 
of standards beyond those thus prescribed by the state is an indica- 
tion that there exists a professional or popular demand for safe- 
guards not yet required by the authorities. Such a movement, 
expressing high ideals, stamps as substandard the hospital which 
does no more than conform to the modest requirements of the law. 

In a large country, where educational and social conditions are 
not uniform, the highest standards cannot be widely established or 
uniformly maintained either by law or by voluntary associations, but 
conscientious effort to determine and define those things which are 
the indispensable attributes of honest scientific work, for example, 
accurate records of clinical and laboratory observations, may be 
extremely useful. Standardization thus conceived encourages in- 
spection and publicity, and keeps alive a sense of responsibility; it 
promotes a healthy rivalry among hospitals, and generates a de- 
mand for better things. 

IMPORTANCE OF THE HOSPITAL PLAN 

The consideration of the basic principles of hospital planning is 
relevant to the present discussion; for while anywhere and under 
any physical conditions the competent and resourceful physician 
will find a means of helping his patient, a hospital in which many 
physicians are employed cannot function smoothly in the absence of 
a sound physical basis for its operation. The plan of a hospital sug- 
gests, and to a certain extent influences, its development, its organ- 
ization, and its methods of work. Serious attempts have been made 
to insure perfection in hospital organization by means of hospital 



EVENING ADDRESSES 137 

planning, but it is evident that the physical arrangement of a hos- 
pital which is planned and erected at a given moment in the history 
of medicine, cannot do more than meet the requirements of that 
moment. The hospital which is complete today is inadequate to- 
morrow. The most that can be done in the planning of a hospital 
is to satisfy, after careful inquiry, all the demands of the period. A 
constant need of all hospitals at all periods is the need of change, 
and the most important single principle in hospital planning is un- 
doubtedly the principle of flexibility. Other important principles of 
planning are unity, diversity, hygiene, and economy, to each of 
which brief attention is due. 

/. Unity. Modern medical treatment involves a wide variety of 
diagnostic, therapeutic, and nursing procedures, and an elaborate 
domestic economy. A well-ordered hospital necessarily contains 
many clinical and other subdivisions; the specialized character of 
these subdivisions readily suggests the splitting of the hospital into 
many parts and hence the architect is apt to be led away from the 
fundamental idea that the hospital is an organic unit, which cannot 
function vigorously unless all of its departments work in harmony; 
but upon the due recognition of this principle of unity the successful 
operation of the hospital largely depends. 

2. Diversity. A glance at hospital activities at once discloses many 
diverse functions. There are patients to be cared for in bed and out 
of bed, indoors or out of doors, singly or in groups, in delirium or in 
convalescence. There is food to be prepared and distributed; there 
are linens to be washed, dressings to be sterilized, accounts to be 
kept, valuables to be stored, visitors to be received, nurses to be 
taught, housed, fed, and provided with opportunities for recreation; 
there are operations to be performed, X-ray examinations to be 
made, refuse to be destroyed, coal to be stored and burned, animals 
to be housed, culture media to be prepared, chemical analyses to be 
performed, postmortem examinations to be made, funeral rites to be 
conducted; and the hospital building must lend itself to the con- 
venient performance of all of these tasks. Certain principles of 
orientation and arrangement are valid, respectively, for particular 
departments of a hospital. If the architect considers separately each 
distinctive function and plans for it appropriately, a variety of 



138 PEKING UNION MEDICAL COLLEGE 

structural outlines will emerge. If he then proceeds to build for each 
function, regardless of its place in the general scheme, chaos will 
result. While the value of diverse forms must be recognized, the 
necessity of combining these forms into a practicable unit must not 
be overlooked. On the other hand, if a plan is adopted which is too 
simple and which is selected on account of its correspondence to 
some particular hospital function, the resulting building may be 
satisfactory in part but will not give satisfaction as a whole. 

j. Flexibility. A hospital building, in which the qualities of unity 
and diversity have been happily blended, may be a perfect instru- 
ment at the time of its completion, but, as I have already said, un- 
less a certain measure of flexibility is added, the building will not 
long serve as a perfect instrument. Social changes, community 
growth, scientific discovery create new demands which every hos- 
pital is called upon to meet. Healthy hospitals are growing hospitals, 
but their growth is not necessarily symmetrical. New discoveries 
are constantly opening up new lines of medical treatment which call 
for additional space-consuming therapeutic apparatus. Nursing 
standards, and the methods of recording work done are forever 
advancing. A hospital which begins as a medical boarding house is 
eventually called upon to participate in health education, in the 
clinical training of medical students, in postgraduate medical teach- 
ing, in scientific research. A sudden windfall enables the hospital to 
enlarge some clinical department or to establish a children's health 
center. Pressure is constant, both from within and from without, 
and the hospital must be in a position to accommodate itself to every 
reasonable demand. 

4. Hygiene. Hygiene is the most vital of all principles in hospital 
planning; a hospital which is not rich in health values is a failure. 
Health values in hospital construction do not reside exclusively in 
smooth walls, smooth floors, and rounded inner corners, but include 
certain features or characteristics which tend directly to the promo- 
tion of health, such as the proper orientation of wards, the sun 
exposure of balconies, roofs, or other outdoor space accessible to 
patients, effective ventilation, quiet bedrooms for night nurses, 
proper dormitories and recreation rooms for all resident officers and 
employees, a cheerful and tonic outlook; and also features which 



EVENING ADDRESSES 139 

aid in the prevention of disease, such as receiving wards, quiet 
rooms, isolation wards, sterilizing equipment of many kinds, and 
sanitary construction. 

5. Economy. It is a mistake to consider building cost apart from 
maintenance cost. Broadly speaking, economy of use is more im- 
portant than economy of production. A metal door frame may be 
cheaper in the end than one of wood, a tile floor in the final analysis 
may be cheaper than one of composition, a white metal faucet may 
be cheaper than a red, a copper cornice cheaper than one of galvan- 
ized iron. Durability is not extravagance. Extravagance in hospital 
construction resides in excessive decoration; in the use of costly 
materials which are not durable or easy to care for; in waste of 
space. Generally speaking, a concentrated institution is the cheapest 
to build and to operate, but in our discussion of the diversity of 
hospital function we saw that extreme concentration and simplicity 
of design ultimately defeat their own ends. An economical hospital 
is one in which every cubic foot of construction gives maximum 
prolonged service. 

Systematic consideration of the details of hospital planning 
would be somewhat out of place in the present discussion, but I 
may at least be permitted to emphasize how indispensable to effi- 
cient work are wards in the planning and arrangement of which due 
consideration has been given to the personal comfort and the pri- 
vacy of patients, to the requirements of case grouping for purposes 
of study, to the value in certain disease conditions and in most 
climates of treatment out-of-doors, to the need of suitable examin- 
ing and treatment rooms, to the installation and placing of the ap- 
paratus which modern nursing service demands. Outside of the 
wards, apart from the always present and indispensable kitchen and 
laundry, the heating, lighting, and power plant, and the business 
offices, departments which on account of their intimate relation to 
the clinical and scientific functions of the hospital and to staff 
efficiency call for the most careful consideration in hospital planning, 
are the admitting and social service departments, the out-patient 
department, the diagnostic and research laboratories, various thera- 
peutic departments, diet kitchens, record rooms, library, teaching 
rooms, and residential quarters for doctors, nurses, and others. 



i 4 o PEKING UNION MEDICAL COLLEGE 

GENERAL CONSIDERATIONS 

Lack of time forbids any attempt to examine at length the details 
of the medical, nursing, and business administration of the hospital, 
but I wish to record my conviction that in the field of acute diseases 
the general hospital in which the clinical specialties are combined, 
and in which alone a proper co-ordination of effort can be secured, 
is preferable to a multitude of separate specialized hospitals, or to a 
loose aggregation of independent institutes which favor isolation and 
which afford no automatic corrrective for the mental habitude of the 
specialist. That in-patient and out-patient services are best con- 
ducted under single control and with the members of the same staff 
functioning in both departments, and that it is contrary to the best 
interests of physicians, of patients, and of society, to establish hos- 
pitals for the exclusive benefit of either rich or poor, I firmly believe. 

Teaching is not a function of the university hospital alone. 
Hospital staffs everywhere should cultivate the teaching habit, and 
their efforts to do so will be richly rewarded by public and profes- 
sional recognition and by enhanced usefulness. It is with feelings of 
mingled admiration and pity that one contemplates a hospital 
which ministers successfully to its patients and to its patients alone 
— admiration for its beneficent work; pity for its failure to make its 
work count to the advantage of all of the sick of the locality, a result 
which can readily be won by encouraging physicians not identified 
with the staff to use the laboratory facilities of the hospital, to con- 
sult its library, to visit its wards, and to attend its clinical confer- 
ences. 

The hospital which aims to reach the highest pinnacle of useful- 
ness will conduct a school of nursing, but will not assign to its 
younger pupils tasks for which they are not yet fitted. It will be 
careful in the choice of those who instruct its pupils, and will pay 
them adequately. It will keep in mind the need of mental stimula- 
tion for instructors and supervisors, as well as for pupils. To over- 
come the tendency to mental stagnation, it will vary the tasks of its 
permanent staff from time to time, will provide a well-furnished 
library for their use, and will arrange lectures and demonstrations 
for their benefit. It will exclude from the school those who are not 
physically fitted for nursing work, and will guard the health of its 



EVENING ADDRESSES 141 

nurses by limiting the hours of their employment, by providing 
suitable dormitories, by furnishing plenty of wholesome food, by 
installing facilities for recreation, by establishing a system of pe- 
riodic physical examinations, and by applying the most approved 
scientific means for the prevention of diseases to which nurses are 
exposed. 

Throughout the hospital there must be respect for all its workers 
as well as tender regard for the sick; the spirit of service must be 
shared by all. Brilliant physicians cannot preserve the sanctity of a 
hospital which disregards the needs and rights of its most humble 
workers and thus deprives them of self-respect and of a sense of the 
usefulness and importance of their work. In the ideal hospital, the 
health of the workers will be deemed as precious as that of the pa- 
tients; and, lest under the pressure of a multitude of tasks this essen- 
tial duty be forgotten, let me urge each hospital to keep a record of 
the sickness occurring among its employees, so that the duty of 
maintaining among the working population of the hospital a sick- 
ness rate at least as favorable as that which prevails in the commu- 
nity at large, may never be forgotten. Let the hospital be a real 
health center for the members of its own organization. 

A moot question among hygienists is just what constitutes an 
ideal unit for purposes of health administration. I am confident that 
a big city is not such a unit; for, although for the purpose of control- 
ling environmental factors which are inimical to health, large-scale 
organization is necessary, the creation of health habits in the indi- 
vidual may be regarded as the foundation of public health, and in 
a great community the individual is beyond the effective reach of 
central authority. It has been said that the family is the ideal ad- 
ministrative health unit; the school is by some so regarded, the 
workshop by others. But the hospital is family, school, and work- 
shop combined. Conceived in a spirit of service for the protection 
and promotion of health, possessed of every known resource for the 
attainment of its object, the hospital, whether public or private, 
sectarian or non-sectarian, while striving to render perfect service 
to its patients, should aim to become a model household, where 
health and happiness prevail. 



HOOKWORM CONTROL AS A PROMOTER OF PUBLIC 

HEALTH AGENCIES 

By 

Victor G. Heiser, M.D. 

INTRODUCTION 

One hundred thousand persons die each year in the United 
States because they swallow some portion of the discharges of other 
people. One hundred thousand die each year in the Orient from 
beri-beri. Thousands upon thousands die annually in India from 
snake-bite. The deaths are only a part of the huge damage done, and 
for every person who dies there are from three to ten who are ill for 
days or weeks and often undergo some form of acute suffering. 

Modern medical knowledge has long since discovered the means 
for controlling diseases due to the above causes, but administrative 
science or the art of application has not yet brought relief to a suffer- 
ing world. It was largely with the hope that some contribution to the 
application of knowledge might be made that the International 
Health Board of the Rockefeller Foundation was organized. In 
order that a test might be made of methods that promised favorable 
results, a brief survey of existing administrative health methods was 
made. It became clear that all too frequently laws were enacted for 
which the public was not ready and for which it had not been edu- 
cated. It is well to remember that for many years much of the world 
has been tending more and more toward democratic ideals and the 
dogmatic knowledge imposed from above is resisted by the people, 
sometimes by active but more frequently by a form of passive re- 
sistance and indifference. Sometimes a group of intelligent, public- 
spirited medical men and well-informed laymen have drafted legis- 
lation for the correction of obvious mistakes in public health 
methods. Legislators elected by popular vote generally fail to show 
interest in legislation of this kind, but by intensive propaganda and 
other methods legislators sometimes, as a personal favor to those 
immediately interested, have enacted the legislation. 

142 



EVENING ADDRESSES 143 

PUBLIC HEALTH LEGISLATION AND EDUCATION IN THE SOUTH 

Probably the first contact which the public had with laws of this 
kind was some form of prohibition, that is, a fine was threatened 
for failure to comply with health regulations. It was inevitable then 
that laws which came into existence under such circumstances 
seldom had popular support and consequently failed. If progress 
was to be made it was obvious that legislation should come upon 
the demand of the people rather than in spite of it. It was believed 
that if some single disease could be chosen which was widespread 
throughout the world and which lent itself to practical demonstra- 
tion, the education of the public could be most easily accomplished. 
After considerable search it was decided that hookworm infection 
might serve the purpose of education. In order to test the idea, a 
million dollars was given to try the theory in the Southern States 
of America. When this matter was proposed to the Southern people 
it can be truthfully said that an idea seldom met with a more hostile 
reception, but by educational measures and patience, public opposi- 
tion was overcome and when it began to be appreciated that real 
benefits to the individual could be secured by the application of 
hookworm measures, the public was inclined to listen more and 
more. Those connected with the treatment of hookworm disease 
in the Southern States were told to explain to the people among 
whom they worked that the same means that would prevent infec- 
tion from hookworms would also be effective against the so-called 
intestinal-borne diseases. Typhoid fever, dysentery, cholera, and 
diarrhoea are conspicuous examples. Work was begun primarily 
among school children, but when the parents noticed how greatly 
their physical condition improved and when it became evident that 
in many instances their mentality also improved, intense interest 
was soon manifested. Very often the parents could be reached 
through the child. They began to ask for examination and were 
ready to take treatment if they were found to be infected with hook- 
worms. Experience along these lines soon showed that if the indi- 
vidual can feel the benefit of a so-called public health measure in his 
own person, he soon shows an intelligent appreciation. It was by 
personal experience that a concept was formed in the minds of the 
Southern people of just what was meant when the term "public 



i 4 4 PEKING UNION MEDICAL COLLEGE 

health" was used. Frequently the question was asked of the doctors, 
"If you can stop typhoid fever and similar diseases, why don't you 
stop them?" The answer was obvious. Before measures against such 
diseases as typhoid fever can be taken, an organized public health 
department is necessary. Having seen the benefits following the 
treatment for hookworm diseases, a large part of the public was 
ready to venture further into the public health field and almost for 
the first time in the history of the United States popular demand 
arose for spending part of the revenues of the country for the crea- 
tion of health services and the employment of competent health 
officers. When measures against hookworm disease were instituted, 
the entire Southern States were spending approximately $250,000 
per annum for health work. In the last ten years public interest 
has increased to such an extent that now, upon the direct demand of 
the people, over $2,500,000 is being spent. In other words, public 
health in the Southern States is annually being safeguarded in a 
truly democratic manner. 

THE INTERNATIONAL HEALTH BOARD 

The success in America led to the creation of the International 
Health Board and the extension of similar methods to countries all 
over the world wherever opportunity offered. The International 
Health Board is now assisting in over thirty countries and govern- 
mental areas in the control of hookworm disease. Further control 
measures of this kind are applied for varying periods and it has 
followed in a large number of instances that a demand has arisen for 
the creation of better public health agencies. 

The International Health Board of course undertakes many 
activities in addition to assisting in the control of hookworm disease. 
Frequently it happens that a scientific method for controlling a 
disease is available, but considerable experimenting may be neces- 
sary in order to arrive at an effective and economical administrative 
method. Preparations for health services throughout the world are 
felt to be too small to justify the spending of funds for purposes 
which do not produce definite results. Under these circumstances it 
often happens that the International Health Board may be of serv- 
ice in undertaking the experiments; and when an effective method 



EVENING ADDRESSES 145 

has been discovered, it can then be taken over by the official health 

agency. 

The control of malarial fever is a conspicuous example. Since it 

was discovered that malaria was transferred by the mosquito, it has 

been obvious that if mosquito destruction could be brought about, 
malaria would cease. The world has not been able to avail itself to 
any great extent of this knowledge because the expense of methods 
of control has been greater than the communities could bear. With 
the hope of discovering simpler methods and practical demonstra- 
tion procedures, the International Health Board began experiment- 
ing in conjunction with state and federal agencies, with the hope of 
providing something within the reach of the average Southern state 
or county. In this they were at least partially successful. It might 
now be said that in the majority of the communities in the Southern 
States malaria can be brought under control at an annual cost of a 
dollar per capita, and frequently with a maintenance cost of fifty 
cents per annum thereafter. Now that the method has been discov- 
ered, many communities are availing themselves of the knowledge 
and putting it into practical effect. In the tropics economical meth- 
ods for the control of malaria in many areas are not yet available. 
With the hope of being able to contribute something toward the 
solution of this problem, experiments are now being undertaken in 
Porto Rico and Nicaragua and it is more than likely that other 
tropical countries will be added to the list. 

It is frequently asked why something is not done toward attempt- 
ing the application of health measures in China. Up to the present 
time it has not been possible to formulate a plan which offers reason- 
able hope of being permanently useful. If health measures are to 
succeed, there must be an official central health agency that is 
efficient. How to create it, is the present problem. The hope for the 
future lies largely in well-trained young Chinese doctors. Perhaps 
they may be able to fashion the wedge which will open the way 
toward a solution, and foreigners may be of some help in assisting 
to drive the wedge after it has once been started. 



u 



INTRODUCTION OF DR. WILLIAM H. WELCH 

By 

General Leonard Wood, M.D. 

Dr. Houghton, Ladies, and Gentlemen: 

I hope you will understand my rather overdecorated appearance; 
I have come here between the courses of an official dinner. I am de- 
lighted to be here and I have come with a very definite purpose. I 
want to invite your friendly attention to conditions of public health 
in the Philippine Islands. We are going to try to steal some of the 
funds of that wonderful combination known as the Rockefeller 
Foundation, which is doing a world-wide work of inestimable value 
to humanity — one of those splendid things which spring upon the 
world from time to time and do untold good. 

We have many difficult problems in the Philippine Islands. We 
have a people who are generous-minded, willing, and anxious to im- 
prove. I think we can say without reservation that no other people 
under the friendly tutelage of another nation has accomplished as 
much in the space of twenty years as have the people of the Philip- 
pine Islands. We have led them through the bewildering mazes of 
government, and sometimes in our impatience we have forgotten 
the swamps through which our own people struggled to attain suita- 
ble government. In this respect the Filipinos are doing very well. 
But there is still a great field for work in public health. We have one 
great experiment which I hope we shall bring to a successful termina- 
tion, that is the demonstration of the curability of leprosy. Dr. 
Heiser, who was responsible for the carrying on of this work in the 
old days, is going down again for a time. We have six thousand lep- 
ers assembled on one island, and I believe that we have the means 
of curing 50 or 60 per cent of them. We have a wonderful opportu- 
nity in the Philippines to demonstrate whether or not we have the 
cure of this terrible scourge, and when I take over my new duties 
there I am going to try to push this work forward. We have also an 
opportunity to do more and more work in Asiatic cholera. Indeed, 
I think that the medical work in the Far East is one of the most 

1 46 



EVENING ADDRESSES 147 

important tasks that can be undertaken. It can be said truthfully 
that the average Filipino is born, lives, and dies without medical 
treatment or nursing. There are few doctors, great areas without a 
hospital, and very few dispensaries. There is a great opportunity to 
build up a splendid health service. We want to build up the School 
of Tropical Medicine, which formerly was one of the best in the Far 
East. We want to re-establish the Bureau of Science, which is doing 
very valuable work but has fallen upon evil days. And we want per- 
sonnel. We want co-operation and interest. 

I feel that the experiment in government in the Philippine Islands 
reaches not only every portion of the Islands but also all peoples 
who are struggling with self-government and who have ideals of a 
republican form of government. We are going to make this experi- 
ment a success. 

I am here tonight primarily for the purpose of presenting to you 
a man whom you all know, an old friend of mine, a man who has 
done a great work for science, and through science for humanity; 
one of those men whose lives have been fruitful in great lessons, 
who have accomplished something for mankind, something which 
will endure as long as our race endures. I want to present to you Dr. 
William H. Welch of Baltimore, the father, — the dean, I should 
say, — of modern *medicine, a man who has the respect of the 
medical profession jdl over the world and the love of all who know 
him. 



THE ADVANCEMENT OF MEDICINE AND ITS CON- 
TRIBUTION TO HUMAN WELFARE* 

By 

William H. Welch, M.D. 

INTRODUCTION 

Dr. Houghton, General Wood, Ladies, and Gentlemen: 

I am sure I am expressing the sentiment in the mind of everyone 
present in telling General Wood how gratified we are that he is able 
to be here even for these few moments. It is not the first time that 
he has done me personally this great service, always with this very 
generous estimate of the little I have stood for and have been able 
to accomplish. General Wood's name is honored in every assem- 
blage of medical men. Doubtless you know the part he played in 
that interesting story, told to us in so fascinating a way by Dr. Vin- 
cent the other evening. I have heard General Gorgas say that he 
doubted whether the Yellow Fever Commission, headed by Walter 
Reed, would have been able to accomplish the purpose for which it 
went to Cuba, had not General Wood been Governor at the time, 
because he so fully appreciated the significance of the results de- 
sired. You will recall that Reed's experiments were carried out upon 
human beings, fortunately without loss of life, and, with full knowl- 
edge of what he was doing, he assumed the responsibility for these 
experiments. At that day the lower animals were not known to be 
susceptible to yellow fever; and although Noguchi has since shown 
that it is possible to use them in experiments on yellow fever, 
nevertheless it is doubtful whether the discovery of the mode of 
transmission of the disease could have been made without its trans- 
ference to human beings. Everything possible was done by General 
Wood to facilitate the work of Reed and his colleagues. It is perti- 
nent to the theme I wish to speak about tonight to call attention to 
the great service which a man in authority at that time was able to 
render to a group of scientific men. We owe him a great debt, and 
his name is to be honored not only for his service in other fields, but 
also for his service to medical science. 

*From stenographer's notes. 

148 



EVENING ADDRESSES i 49 

On this occasion — the formal opening of the buildings and hos- 
pital of the Peking Union Medical College — I wish to speak first 
of the great hopes which I have for the contributions of the college 
to medical education and knowledge and thereby to the prosperity 
of this great country. 

The theme I have chosen for my remarks this evening — the 
advancement of medicine and its contribution to human welfare — 
is one which I selected deliberately when learning that it was de- 
sired that I should speak during these exercises, knowing that it 
would be impossible for me to treat the subject in any comprehen- 
sive way. It is a subject so broad and general in character, however, 
that I realized that it would enable me to talk upon almost any 
topic, for there is practically nothing in medicine that cannot be 
discussed under this heading. 

It seems to me worth while on this occasion to consider to some 
extent what have been the circumstances which have tended to the 
advancement of medicine. Scientific men give, as a rule, very little 
thought, from a philosophic point of view, to the particular methods 
which they employ. A great philosopher, Francis Bacon, attempted 
to indicate how science was to be advanced. In his Novum Organum 
he set forth in great detail an elaborate system, which he conceived 
would, if applied, lead to the advancement of knowledge in every 
field of science. Of course it was a great contribution to human 
thought, and marks an era in the history of philosophy. But Ba- 
con's work, important as it is from the side of philosophy, has never 
made quite the same appeal to investigators in science; the judg- 
ment of his own physician, whose name as an investigator is one of 
the greatest in the whole history of medicine, William Harvey, is 
that of many a man of science, namely, that Bacon talks about 
science as one might expect a Lord Chancellor and philosopher to 
talk. Bacon had no conception of what was really going on. Harvey 
and a great contemporary, William Gilbert — two great men of 
that period — together with Galileo and Keppler, introduced the 
era of experimental science. But little mention of the discoveries of 
these men is made by Bacon. This is an illustration of how nearly 
futile it is to attempt to indicate the precise methods by which 
science, natural or physical or medical, is to be advanced. 



150 PEKING UNION MEDICAL COLLEGE 

EARLY HISTORY OF SCIENCE 

Nevertheless it is worth while to pause and look backward and 
draw lessons from the history of these sciences as to what in the past 
has contributed to their progress. Natural science, of course, is 
advanced by observation and by experiment, and the dividing line 
between the purely descriptive or observational period and the 
experimental period is rather sharp. These periods are fairly well 
defined by the year 1600, at which time the testing of theories, 
speculations, and hypotheses by experiment came to be recognized 
as of supreme value. Practically all medicine before that time was 
observational. Experiment is, of course, observational; it is observa- 
tion under controlled conditions — conditions deliberately set up 
by the experiment. This period, then, introduced by the work of 
Harvey for medicine and by Galileo for physical science in general, 
brought a new era into the history of science. 

I may say here in passing that it is worth while considering how 
far the mere observation of the phenomena of disease can bring us, 
and that it seems to me it is only fair to compare Chinese medicine 
with that observational period; that is, with Western medicine as it 
existed before the year 1600. We heard the other day at the Dedi- 
cation Exercises from the Minister of Education that there were 
ancient Chinese students of disease. But their theories were re- 
solved, one might say, into formulae, and native Chinese medicine 
has never entered upon the period of experimental science, as 
Western medicine has done. I think it would be very interesting to 
make some comparison between the knowledge obtained in Western 
medicine by the mere observation of the phenomena of disease and 
the knowledge that has been secured by the Chinese observers. 

THE BEGINNING OF RATIONAL MEDICINE 

We usually begin our history of rational medicine with the name 
of Hippocrates. What existed before his time is more or less in the 
nature of folklore, and was largely priestly medicine. This has, in- 
deed, never died out. It has always existed side by side with ra- 
tional medicine. Though it has always been a thorn in the flesh to 
the regular doctor, this method for the cure of disease by influence 
over the mind — faith cure, or psychotherapy — is a perfectly legit- 



EVENING ADDRESSES 151 

imate method of cure and is to be studied in its effects. Rational 
medicine begins, then, with the name of Hippocrates, in the most 
brilliant period of ancient Greece, the Periclean Age. His name 
typifies the observation of disease unhampered, relatively at least, 
by speculations and theories, and stands so definitely for the direct 
line of approach to the study of the phenomena of disease that to 
this day we speak of the Hippocratic method, meaning a method of 
the objective study of the symptoms of disease as they present 
themselves at the bedside, with little aid from other sciences — 
anatomy or physiology — and little influenced by speculation or 
theory. It is not quite certain, however, that Hippocrates was so 
uninfluenced by speculation and theory as we are led to suppose. 
The writings which go under the name of the Hippocratic writings 
consist of the genuine writings and the false writings. The so-called 
pseudo-Hippocratic writings are eliminated from the genuine writ- 
ings largely on the basis of whether or not they contain speculative 
doctrines. But since the discovery some years ago of the note-book 
of a contemporary student, whose comments, there is evidence to 
believe, are from the genuine Hippocratic teachings, and contain a 
great deal of speculation, I think that the conception that Hippoc- 
rates was uninfluenced by speculation and theory is not altogether 
well founded. 

There have always been periods in the history of medicine when 
a wholesome cry has arisen, "Back to Hippocrates," meaning that 
those who have become entangled in speculation and theory, whose 
studies seem to be rather remote from the practical problems of 
disease, should turn back to the solid ground on which Hippocrates 
stood; to the straightforward, clear, unhampered observation of the 
phenomena of disease. His method stands today as important as it 
has always done. I do not propose to indicate here, even briefly, the 
progress which it was possible to make by that simple method of 
studying disease, but there are one or two points to which it may be 
worth while to call attention. Hippocrates was eminently sane in his 
views. He believed in natural causes for the origin of disease. It was 
a bold step forward when he made the statement concerning epi- 
lepsy, which was called the morbus sacer, that this disease was no 
more sacred than any other disease, meaning that it was due as 



152 PEKING UNION MEDICAL COLLEGE 

much to natural causes, mysterious as these might seem to be, as 
was any other disease; that all disease could be traced to natural 
causes. He had a conception as to certain essential points connected 
with epidemics. His work on airs and waters and places is the be- 
ginning of sanitation — it is a classic. His observations and his 
books on epidemics are valuable even to this day, and one can go 
back to those books and read descriptions of disease which have 
hardly been surpassed since. All this was accomplished by the clear 
observation of the phenomena of disease. 

DOCTRINE OF CONTAGION 

It is curious that most of the writers of classical antiquity had 
little or no conception of the conveyance of disease by contagion 
from person to person. One might think that such a conception 
would be very obvious, but as a matter of fact the doctrine of con- 
tagion plays very little part in the writings of Hippocrates and of his 
successors, even as late as Galen in the second century after Christ. 
Galen believed that the diseases which we now call the infectious 
diseases were spread very largely through air, through contami- 
nated air, often emanating from vitiated surroundings, such as 
swamps. This very important conception of contagion originated 
long before the experimental era, and illustrates a point of impor- 
tance, namely, the progress of medicine due to devastating epidemic 
diseases; for one may sometimes question whether the saving of 
human life from the careful study of great pestilences has not been 
larger than the loss of life by such scourges. The doctrine of con- 
tagion was brought forcibly to men's minds by the great epidemic 
of the Middle Ages, the "black death," which was probably the 
pneumonic plague. Then there were leprosy, smallpox, and typhus, 
and also syphilis, which made its appearance in Europe toward the 
end of the fifteenth century. 

Very interesting views, therefore, as to the nature of contagion 
were reached without any experimentation at all but simply by 
study and analysis of the manifestations of contagious diseases. 
The work of Fracastorius on this subject appeared in the early 
part of the sixteenth century. He, by the way, was a humanist and 
a poet, and his name is of importance in the Renaissance, in the 



EVENING ADDRESSES i 53 

revival of letters. His great work on contagion is amazing and 
almost modern in its inferences and arguments. One almost expects 
him to say, although he does not, that contagion is something alive. 
He says it is not of the nature of a poison, because it propagates 
itself among an indefinite number of persons and can spread from 
person to person. He speaks of the seeds of contagion and points 
out their characteristics; that they spread sometimes by direct con- 
tact, sometimes by very indirect contact, and sometimes by articles 
contaminated by persons and not directly from person to person. 

MODERN ERA: THE STUDY OF ANATOMY 

The modern scientific period in the history of medicine, although 
still purely observational, began with the dissection of the human 
body, with the study of anatomy. This period is often spoken of as 
the revived study of human anatomy, because there is evidence that 
human dissection was done far back in that ancient period about 
which we know so little, the Alexandrian period, from about the 
time of the death of Alexander, 322 B. C, on for three or four cen- 
turies — a very extraordinary period, the writings of which are 
lost. I should like to mention that what we know of this period is 
obtained largely from the writings of a non-medical man, Celsus, 
who is the only authority we have for the statement that vivisection 
upon human beings was done in the Alexandrian period. I have 
never felt that the statement of a lay writer such as Celsus, writing 
over two centuries later, should be accepted as conclusive, for vivi- 
section upon the human body is not mentioned by Galen nor by 
any other of the medical writers who refer to the Alexandrian school. 
A positive statement, therefore, that human beings were vivisected 
for scientific purposes in the Alexandrian period is, to say the least, 
very doubtfully founded, although some medical historians do 
accept it. 

The study of human anatomy was revived with great success by 
Vesalius in the middle of the sixteenth century. Its immediate sig- 
nificance was less for practical medicine than for the sharp break 
which it made with the acceptance of authority through tradition, 
which since the time of Galen had shackled the progress of medicine. 
From the middle of the sixteenth century human anatomy came to 



154 PEKING UNION MEDICAL COLLEGE 

occupy a very important place in medical education; and it was the 
only subject, until comparatively recent years — that is, until 
about one hundred years ago — with which the medical student 
came directly into intimate and personal contact. The rest was 
taught him by lectures and demonstrations. He learned only 
by being told about things, or reading about them. The study 
of anatomy had then, therefore, an educational value which it 
can hardly be expected to possess so exclusively today, although 
I do not for a moment mean to imply that it is not of the utmost 
value today. 

The introduction of the modern era in medicine by dissection of 
the human body is worth dwelling upon for a moment in its relation 
to the situation in China today. When I was here in 191 5 I attended 
a banquet to which many distinguished Chinese scholars had been 
invited to meet our commission. There was a great scholar present, 
the most distinguished, I was told, of the province of Hunan, one of 
the literati and a man greatly honored by the Chinese. After others 
had spoken there were cries from the Chinese in the audience for 
this man to speak. He made the following statement, which I have 
never forgotten: "While I have been sitting here I have been think- 
ing, 'Why is it that Western medicine has so far outstripped Chi- 
nese medicine?' They started together, with the same object, the 
observation and cure of disease. One has gone ahead and the other 
has lagged behind. I think it is because we stopped dissecting the 
human body in the time of the Han dynasty." It is to a large extent 
the extraordinary ignorance and really fantastic ideas about the 
anatomy of the interior of the human body which have held native 
Chinese medicine enchained. 

EXPERIMENTAL MEDICINE: PROGRESS IN PHYSIOLOGY 

As I have said, there came into medicine the experimental method 
early in the seventeenth century. Medicine has usually kept pace 
with the great periods of advance in the natural and physical sci- 
ences. When these sciences are decadent, medicine is decadent or 
unprogressive. The great period of the seventeenth century, the 
period of Galileo, Keppler, and Newton in the physical sciences, of 
Bacon, Descartes, and Leibnitz in philosophy, and of Harvey, 



EVENING ADDRESSES 155 

Malpighi, and Sydenham in medicine, is comparable only with the 
nineteenth century in its awakening of human thought and in the 
rapid progress made in knowledge, and particularly in those branches 
of knowledge to which the experimental methods available at the 
time are applicable. There was great progress particularly in phys- 
iology. It is difficult even to conjecture what medicine would be 
without a knowledge of the circulation of the blood. The discovery 
of the circulation of the blood is, of course, one of the most brilliant 
achievements of the experimental method — an achievement ob- 
tained by experimentation upon animals, which doubtless could not 
have been obtained in any other way. And I may say here, in reply 
to the antivivisectionists, that the experimental method is as essen- 
tial to the progress of medicine as it is to chemistry and to physics. 
It involves experimentation upon the lower animals, and it necessi- 
tates, of course, a high sense of responsibility in the carrying out of 
the experiment, which should be done always for a serious purpose 
and with every precaution to avoid the infliction of unnecessary 
pain. Fortunately today such experiments can be carried out under 
anesthesia without pain. We must not forget how fundamental is 
the debt we owe to vivisection. Even doctors themselves are rarely 
concerned with the origin of the knowledge they possess, and usu- 
ally when we have to make statements to the general public, as in 
sessions of the legislature, or in a political campaign such as that 
recently in California, we cite concrete instances of the great bene- 
fits to and saving of human life from the experimental method, 
without pausing to think that without the results of experimenta- 
tion we should not today be making intelligent observation of 
the pulse, or respiratory phenomena, or digestion, or the nervous 
system, or disturbances of external and internal secretions. We 
can now draw conclusions which would be quite impossible with- 
out the knowledge of physiology obtained from the purely experi- 
mental studies which the antivivisectionists are inclined especially 
to decry. 

A great name of this century in medicine is that of Sydenham, 
who is often spoken of as the English Hippocrates, because, like 
Hippocrates, he gave little thought to allied sciences, even to anat- 
omy and physiology, but confined his observations almost exclu- 



156 PEKING UNION MEDICAL COLLEGE 

sively to studies at the bedside. But it is not correct to say that the 
observational period is without its hypotheses and theories and 
speculations. Indeed those who most pride themselves upon being 
free from theories are often the most controlled by them. As an 
instance : until the seventeenth century the dominating theoretical 
doctrine of the origin and nature of disease was the so-called hu- 
moral doctrine, dating from the time of Hippocrates and Galen, the 
doctrine that disease was due to disturbances in the fluids, as con- 
trasted with alterations in the solids of the body. This humoral doc- 
trine was so inherent in men's minds that it controlled their practice. 
It was considered that there was a something, called "the matter of 
disease," the materies morbi, and that this must be eliminated from 
the body before persons could recover from their disease. Hence the 
use of cathartics, diuretics, venesection, and so forth. Here I may 
illustrate how progress is often made by purely empirical methods, 
often, one might say, by accident. A drug was introduced, the cin- 
chona bark, which came from South America, introduced by the 
Jesuit Fathers from Spain, which cured malarial disease without 
question, and cured it without any critical discharge from the body. 
One can hardly conceive at this day why there should have been 
such a tremendous opposition to its introduction in the treatment of 
disease; but at that time its operation was simply incompatible with 
all the existing theories as to the nature of disease and methods of 
cure. Thus are men's minds often unconsciously tempered by theo- 
ries and speculations. 

As I have stated, there was at this period great progress in anat- 
omy and physiology, and particularly in physiology. One great dis- 
covery I have already referred to, the circulation of the blood. Now 
there arose another conception, the importance of which is not so 
obvious, although it is well known to all physiologists. This relates 
to that important character of living matter known as irritability. 
No inanimate matter responds to external stimuli as does living 
matter. This action on the part of living matter was first noted 
by Glisson, though Haller in the eighteenth century is the one to 
whom credit is usually given. Still later came the discovery of the 
process and nature of combustion by oxidation and its analogy to 
respiration. 



EVENING ADDRESSES 



J 57 



MODERN ERA IN PRACTICAL MEDICINE: PATHOLOGICAL ANATOMY 

But practical medicine, real knowledge of disease, remained on an 
observational basis until the application of pathological anatomy ; 
that is, until the recognition of the part which pathological anatomy- 
can play in the elucidation of disease. This marks the beginning of 
the modern era in practical medicine, towards the end of the eight- 
eenth century, with dissection of the human body in order to find 
out the seat and causes of disease. There had been in the sixteenth 
and seventeenth centuries postmortem examinations, with quite an 
accumulation of interesting facts relating to alterations produced in 
the human body by disease, but the conception that a true under- 
standing of the nature of disease is greatly furthered by a system- 
atic prosecution of postmortem examinations, was not really 
established in the minds of the medical profession until the publica- 
tion of Morgagni's great work in 1761. (This work, I may say, ap- 
peared when he was seventy-nine years old, but the facts had been 
accumulated during his long life.) Now there came a great move- 
ment forward, a movement initiated by the study of the lesions 
produced by disease as revealed at the postmortem table. Fortu- 
nately soon after came the method of physical diagnosis by auscul- 
tation and percussion, and also the great discovery by Lavoisier of 
the part played by oxidation in respiration. Those three great dis- 
coveries were the stimulus for a movement forward previously 
unparalleled in medicine. The most glorious period in French medi- 
cine is, I think, the first two or three decades of the nineteenth cen- 
tury, characterized by the work of those men who with unusual 
ardor and zeal made such remarkable studies of disease by post- 
mortem examinations, and also at the bedside and by auscultation 
and percussion. The great names of that period are Bichat, Laennec, 
and Louis. 

INTRODUCTION OF THE LABORATORY 

In that period came a great advance, the influence of which upon 
the progress of medicine it is hardly possible to overestimate. I refer 
to the introduction of the laboratory. There have doubtless always 
been workshops. It is difficult to imagine that Aristotle did not have 
something in the nature of a laboratory when one considers his. 



158 PEKING UNION MEDICAL COLLEGE 

contributions in the field of natural history. But the laboratory as a 
place for teaching medicine and for research was introduced only 
in the third decade of the nineteenth century. It is usually stated 
that it came in with the establishment of Liebig's chemical labora- 
tory in Giessen in 1825, but this laboratory was antedated by one 
year by the physiological laboratory in Breslau established by 
Purkinje. Liebig was greatly interested in problems of medical 
chemistry, in which field he was a great pioneer, as well as in the 
field of agricultural chemistry. The development of the laboratory 
is what gave German medicine its great prominence and prestige, 
for it was in Germany that its conception and development were 
advanced further than in any other country. I should be the last to 
decry laboratory teaching. It is of the utmost value and is the 
method by which the student is brought into immediate and direct 
contact with the object of study. But you cannot teach the whole 
content of any study in the laboratory; you must select, particu- 
larly in student courses, those aspects of a subject which are ca- 
pable of treatment by laboratory methods. There is a certain lack of 
perspective in purely laboratory studies; they must be supplemented 
by reading, by carefully selected lectures on topics which are not 
included in the laboratory, and by recitations. 

ETIOLOGY 

With advancement in medicine came in the last quarter of the 
nineteenth century a great revolution, the penetration into the 
causes of disease. The era in which we are now living is character- 
ized above all others by a recognition of the importance of under- 
standing the causes of disease, and particularly the importance of 
an appreciation of and insight into the nature and causation of the 
infectious diseases. These which have always aroused the attention 
of mankind, on account of their devastating effects, have a social 
importance possessed by no other class of diseases, due of course to 
the fact that they affect such large numbers of persons at the same 
time and are often accompanied by so extremely high a mortality; 
and also the fact that they affect persons in the earlier periods of 
life — in infancy, childhood, and early adult life. Therefore the dis- 
covery of the causation and of the methods of prevention of this 



EVENING ADDRESSES 159 

class of diseases has a social, a racial significance which the discovery 
of the causation of the organic diseases of advancing life does not 
possess. Some of us doubtless would welcome an insight into the 
diseases of advancing life, if it were attended by methods of pre- 
vention and of cure. But the loss of persons who are reaching a 
period in which their activities are of less significance to society is 
not so deplorable as the loss of members of the younger generation. 

SOCIAL ASPECTS OF MEDICINE 

This line of advance, therefore, has really changed the face of 
modern medicine and given it a social and racial significance pre- 
viously unknown. The discoveries in the field of the causation of 
infectious diseases have made laymen appreciate the importance 
of furthering the progress of medicine. And those are the diseases of 
greatest importance here in China. We who stand a little apart are 
filled with envy of those who are attacking this problem here, be- 
cause you have a relatively unexplored field. I wish to pay tribute 
to all the work that has been done by the medical missionaries and 
others in the Orient; but they would be the first to concede that 
there are here open problems of the greatest importance for the 
saving of human life and the relief of human suffering. 

These then are some of the things that have occurred to me to say, 
as influencing the progress of medicine. I should like to allude for a 
moment to the things that attract men to enter the field of science, 
and of medical science more particularly. I should like to refer to 
the rewards. And by rewards I do not mean merely financial re- 
wards. I mean the satisfaction which comes from careers in these 
fields, the intellectual satisfaction, and the satisfaction derived 
from the respect and appreciation of one's fellow-members of the 
community. That kind of appreciation is very essential to the 
progress of science and of medicine. It is widely given in France and 
in Germany, with the result that a larger proportion of their best 
and ablest talent has been attracted to the field of science. I do not 
think the same can be said in equal measure of our country, Amer- 
ica, where the rewards have been greater in other fields. Those who 
possess a distinct gift for advancing knowledge, a distinct gift for 
discovery, are comparatively rare, and therefore the larger the 



160 PEKING UNION MEDICAL COLLEGE 

number who are attracted to enter such careers, the greater the 
chances of there being among them this relatively small number pos- 
sessing the capacity for fruitful investigation. This element of 
appreciation is, therefore, extremely important. It is, I think, some- 
thing to be cultivated, and I believe it will come here in China. 

I have not spoken about certain qualities in those who have been 
the great discoverers in medicine and who have contributed so 
largely to the progress of medical science. I think it is extremely 
important for young men to familiarize themselves with the lives of 
those who have devoted themselves so unselfishly and successfully 
to scientific discovery. Among such I would single out the lives of 
Harvey and Pasteur as particularly stimulating and inspiring to 
young men. Two excellent lives of Pasteur, one by Yallery-Radot 
and the other by Duclaux, have been translated into English. All 
that I have said tonight is exemplified by the life and example of 
such men as Pasteur. 

Science has progressed in different ways in different countries. 
The great agency in France and Germany has been the university. 
In England the characteristic note has been independent investi- 
gation, a certain quality of independence, rather dissociated from 
organized effort in universities or societies, characterizing English 
progress. In America progress has been very largely associated with 
the development of medical education. At this point I should like to 
say that the success of independent institutes of research is de- 
pendent upon sound medical education. You cannot divorce re- 
search from university education. The supply of men who are to 
engage in such work must come from the universities. Notwith- 
standing the splendid results, fully justifying the establishment of 
independent institutions of research, it is true today that the great 
mass of contribution to knowledge comes from universities and 
medical schools. I believe the time will never come when capacity 
for the advancement of knowledge will not be regarded as an im- 
portant qualification for the teacher in our best universities and 
medical schools, teaching and research thus going hand in hand. 
There will possibly be certain differentiations in the lines of work. 
Certain kinds of work, of great importance, can be undertaken best 
in independent institutions of research; and it may be worth while 



EVENING ADDRESSES 161 

considering to a greater extent than we do today what work is best 
undertaken in universities and medical schools, and what should be 
left to the independent institutions. The establishment of inde- 
pendent institutions of research in no way takes away from the 
importance of the scientific spirit and attitude of mind in the uni- 
versity and in the medical school, but rather should contribute to 
their development. 

CONCLUSION 

I have long overstepped the limits I had set for this address, but 
I wish in closing my remarks to express the thought that is in my 
own mind, and I believe in the minds of all who have had the good 
fortune to be present at the exercises of this interesting week, that 
it has been a week, in the first place, of the greatest enjoyment and 
pleasure, due largely to the hospitality which has been shown us on 
all sides, and that it has been also a week full of inspiration. It has 
brought those of us who have come from the West into personal 
contact with the problems and the situation here which I think is 
going to be of great importance to us, and which I hope will be of 
importance to you. We understand your problems better for having 
been here. We shall watch with the greatest interest and confident 
expectation the work which is done here. I have not dwelt this 
evening upon the purposes of this school, because they have already 
been set forth so ably and so fully in other addresses. But you may 
be sure, those of you who are workers here, and indeed in other 
places in China, that you are not lost sight of; that we shall eagerly 
follow your work and shall take a great interest in it; that you are 
as much a part of the world of medicine as though you were in your 
native countries. I also desire to express the confident hope that the 
purposes for which this school was established will be fully realized, 
and that it will serve as a beacon light and a center from which will 
radiate knowledge for the saving of human lives and for the welfare 
of this great country. 



12 



MORNING ADDRESSES 



SALUTATORY 
By 

George E. de Schweinitz, M.D. 

It is altogether fitting and proper that an expression of deep 
appreciation should be made, in which appreciation all my friends 
and colleagues from the Western world join, in that we are privileged 
to visit these beautiful buildings, erected on such broad and gener- 
ous plans; to become acquainted with the work which has been done, 
an earnest of that which shall follow; to note the opportunities 
afforded to those who are banded together for the relief of human 
suffering and the prolongation of human life; and to observe the 
lines of research which are being established whereby that suffering 
shall be prevented, that life prolonged, which in other circumstances 
is too easily wrecked, too early cut short. 

I perform a pleasant duty in conveying to the Trustees, Director, 
and Staff of the Peking Union Medical College from the Acting 
Provost and Trustees of the University of Pennsylvania, a message 
of congratulation and good-will. In like manner, representing the 
American Medical Association and fulfilling the directions of the 
Board of Trustees, I extend their salutations and best wishes, in- 
cluding in these greetings those of the large membership of that 
Association, and I bring with me, Mr. Director, formal credentials, 
duly signed and sealed, from the University of Pennsylvania and 
from the Trustees of the American Medical Association. 

Happily for me, it has been my duty to share in the instruction of 
the young men of China who from time to time come to the School 
of Medicine of the University of Pennsylvania, and I desire to bear 
testimony to their outstanding mental capacity, their intelligence, 
their industry, and their insistent effort to succeed. To you, gentle- 
men of the Faculty of the Peking Union Medical College, I offer my 
felicitations in that your students are in largest measure recruited 
from the youth of this great country, who, entering this Temple of 
Medicine (and never before has this descriptive title seemed more 
appropriate), are offered opportunities of unsurpassed value whereby 

165 



1 66 PEKING UNION MEDICAL COLLEGE 

they may acquire an education which shall enable them to extend 
far and wide the beneficent influence of the practice and art of med- 
icine and of surgery and of the conservation of health. May great 
success attend you in all your endeavors. "Two things come not 
back," said the Caliph Omar, " the sped arrow and the spoken word." 
The arrow was found in the heart of an oak, but the spoken word in 
the heart of a friend. I leave with you these few inadequately spoken 
words in the full trust and belief that I leave them, too, in the 
hearts of many friends. 



CONCERNING THE EVOLUTION OF SOME OF THE 

VISUAL PHENOMENA OF PITUITARY 

BODY DISORDERS 

By 

George E. de Schweinitz, M.D. 

INTRODUCTION 

This communication concerns itself solely with clinical observa- 
tions on some of the visual interpretations of pituitary body disor- 
ders, as they have been noted in public and private practice, and as 
they have been studied in the service of Dr. Charles H. Frazier in 
the University of Pennsylvania Hospital, and in some instances, 
through his courtesy, in that of Dr. Harvey Cushing. There is no 
attempt to discuss the matter from the standpoint of literature- 
analysis, surgical procedures, or pathologic investigation. In its 
preparation, five previous papers on this subject have been utilized, 
and a number of the diagrams there employed are reproduced ( i to 5) . 

The term "pituitary body disorders," as employed, is descriptive 
of affections of the hypophysis in general, without, except in inciden- 
tal mention, reference to the type, that is, whether there is excessive 
activity of the glandular epithelium (hyperpituitarism), or whether 
there is diminished function of the anterior lobe (hypopituitarism). 

The important visual disturbances depend, for the most part, on 
compression of the optic chiasm, the optic tracts, and the optic 
nerves, in other words, of the basal visual pathways, and also, in a fair 
percentage of cases, on pressure on the motor nerves (10 to 25 per 
cent). They are the most common neighborhood signs of lesions in 
the hypophysis. Their relation to the size of the sella turcica is, 
however, not constant. Thus, in acromegaly there may be a very 
large sella without any evidence of disturbed visual function. 

If in any case the effects of altered glandular activity should 
manifest themselves in outstanding features (gigantism, acromeg- 
aly, adiposity, and infantilism, etc.), recognition of the condition 
presents no difficulty; nor, indeed, are difficulties in this respect of 
moment, if visual field defects suggest the necessary general investi- 
gations, notably X-ray examination. 

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1 68 PEKING UNION MEDICAL COLLEGE 

EARLY AMBLYOPIA 

But the question arises, and has often been discussed, whether in 
the absence of these "outstanding features" ocular signs in asso- 
ciation with certain constitutional symptoms may not lead to an 
early diagnosis and a correct interpretation. Many patients who are 
subjects of pituitary body disorders in an early stage (usually hy- 
popituitarism), although entirely unaware of the nature of their 
disease, first consult an ophthalmologist, because headache, often of 
a "boring" character, some disturbance of vision, mental apathy, 
or somnolence, are the symptoms for which relief is desired, and 
which are believed to be due to eye-strain. 

In these circumstances, however (at least, in some cases), the 
disturbances of sight cannot be corrected by glasses. It is a form of 
blurred vision of which the patient is definitely conscious, and 
which antedates the amblyopia, associated with nerve-head changes 
and visual field defects, especially scotomas, as ordinarily investi- 
gated. It may last for months (in one case for two years) before 
change in the color of the disc is notable. 

Although twelve years ago, when first discussing this "prodromal 
amblyopia," or preferably "early amblyopia," I stated that a 
scotoma could not be demonstrated, there is reason to believe that 
working with modern methods a minute defect of this character, 
central or paracentral in position, could be found. As this amblyopia 
represents the earliest stage in the evolution of visual defects, its 
accurate investigation may well escape attention, just as its signifi- 
cance has often failed of recognition. The patient's visual acuteness 
(tested with a type card) at first may be normal, or standard, in the 
sense that the letters are correctly read at the proper distance, 
but not clearly, — read, as one patient said, "as if I were in a 
brown study." Evidently this amblyopia indicates the first result 
of beginning pressure or traction. 

SCOTOMAS 

The next step in the evolution is the formation of paracentral 
hemianopic scotomas; later "hemianopic (bitemporal) defects," and 
ultimately more or less complete bitemporal hemianopsia. 

The small paracentral scotoma may develop into a larger bitem- 



MORNING ADDRESSES 169 

poral defect; it may remain small, and the temporal field loss may 
take place from the periphery, usually beginning up and out, until 
approximately the midline is reached, and the whole outer area of 
the field is dark. 1 Occasionally (three instances in my experience) 
coincidently with, or shortly after the appearance of the paracentral 
scotoma, a dark island appears in the area between the fixing point 
and the periphery, into which the darkening of the field from the 
outer margin merges. 

A typical evolution would be as follows: {a) A visual blur not due 
to optical faults, possibly, but not certainly associated with a minute 
scotoma, of varying duration; (b) paracentral scotomas, either en- 
larging into extensive bitemporal defects, or remaining small, while 
the temporal visual field loss proceeds from the periphery; (c) quad- 
ran tic temporal hemianopsia; (d) complete, or practically complete, 
bitemporal hemianopsia (Figures 1 to 7). 

A so-called typical development is by no means constant or uni- 
form. In fact, referring now to the scotomas, they often are "atypi- 
cal" in position and evolution, and for convenience may be classified 
thus: 

1. Scotomas up and out from the fixation point; the larger scotoma 
being in the field of the eye with the poorer vision; later bitemporal 
hemianopsia (for example, Doyne's case (6)) (Figure 8). 

2. Large temporal scotomas, either nearly symmetric in develop- 
ment (Pontoppidan, UhthofF), or larger in one field than in the 
other, the enlargement of such defects associated with shrinking of 
the temporal fields from the periphery, resulting in total bitemporal 
hemianopsia. It is probable that an early stage of these large bitem- 
poral defects consists in the appearance of the smaller paracentral 
(temporal) scotomas before referred to (Figures 9 and 10). 

3. Binasal hemianopic scotomas, with, as in Zentmayer's case, a 
bitemporal color defect; they may be of short duration, in the case 
quoted, only two weeks (Figure 11). 

4. Central scotomas: those which may simulate the scotomas of 

1 Very occasionally the first quadrantic defect is down and out, because the pri- 
mary pressure has been on the dorsal fibers of the crossed bundle which supply the 
upper nasal quadrant layers of the retina. Cushing suggests that the lesion is of 
infundibular rather than of hypophyseal origin in these circumstances. 



170 PEKING UNION MEDICAL COLLEGE 

toxic amblyopia; those which are large and directly central; those 
which are primary in the sense of a first manifestation, and those 
which are secondary in that they may appear, as in Lauber's case, 
during a relapse of sight-disturbance, after a period of release from 
visual defects which may have been typical. Central scotomas are 
not common, but a number are on record (Nettleship, Lauber, 
Kocher, Bartels, Fleischer, A. Knapp, de Schweinitz, O. Hirsch, and 
other reporters) (Figure 12). 

5. Scotomas in other positions: up and out in one field, and di- 
rectly over the fixation point, capping it, in the other field, as in 
a case of Holloway's and mine; unilateral, small and temporally 
paracentral in one field and temporal color defect in the other field; 
or of the usual paracentral position and shape on one side and small 
and directly central on the other (Figure 13). 

Pressure foci in the chiasm are usually made responsible for 
most of these scotomas. Thus, the bitemporal hemianopic scotomas 
may be due to circumscribed involvement of the crossed fibers of 
the macular bundle in the ventral portion of the chiasm; the quad- 
ran tic temporal hemianopsia which so often follows may be related to 
an implication of the crossed ventral peripheral fibers. It is possible 
that a symmetrically extending lesion on both sides of the posterior 
upper surface of the chiasm might affect the uncrossed fibers of the 
papillomacular bundle and produce binasal hemianopic scotomas. 
Even though a central scotoma, suggesting axial involvement, may 
have been the cause of visual disturbances, clear explanation of its 
presence may not be demonstrable at autopsy, as Bartels points out 
(7) ; but local toxemia is certainly an etiologic factor. 

An explanation by J. Herbert Fisher of the genesis of relative 
scotomas of the macular bundle is that the process is the result of 
traction upon, rather than of pressure against, the chiasm, and that 
these macular fibers, owing to their highly specialized function, suffer 
more than the others. Cushing believes that the two conditions, pres- 
sure and traction, go hand in hand (8). 

Another important factor in the development of visual field de- 
fects as the result of basal disease is vascular constriction. This was 
described and commented upon long ago. In 1 852, Turck reported a 
case of carcinoma posterior to the chiasm which pushed this struc- 



MORNING ADDRESSES I?I 

ture into an upward and anterior position; both optic nerves were 
found transversely notched by pressure of the anterior cerebral 
arteries. The notching of the optic nerves in patients with hypophy- 
seal disease has been described by Sachs, the pressure coming from 
the anterior cerebral arteries, byHolloway and myself 2 and also by 
Siegrist. Such notching, or grooving, is not confined to the optic 
nerve; the optic tracts may be similarly affected by pressure of the 
anterior cerebral artery (Uhthoff, Bartels, Erdheim), and the 
chiasm by the anterior communicating artery (O. Hirsch 3 ) (Figures 
14 and 15). 

Because special emphasis has been placed on the development of 
scotomas in pituitary body disease, it must not be supposed that 
such visual field defects are a new discovery. They have been known 
and commented upon from time to time for many years. Foerster 
(10) referred to a number of cases of "medial hemianopsia," as he was 
wont to call this type of visual field defect, which began with small 
negative scotomas in each field, lying close to the outer side of the 
fixation point, and which- gradually increased in size until the whole 
temporal field was involved. That pituitary body affections may be 
etiologically active in this respect Foerster showed in that he quoted 
the case of D. E. Miiller (11), observed more than fifty years ago, in 
which autopsy revealed that the chiasm disease which produced the 
visual field defect was caused by pressure of a tumor of the hy- 
pophysis. 

Twenty-five years ago, Nettleship (12), basing his paper on an 
analysis of ten cases in which failure of vision at or near the center 
of the field in both eyes, with no early ophthalmoscopic changes, 
discussed central amblyopia as an early symptom in tumor of the 
chiasm. While three of them certainly depended upon tobacco in- 
toxication, and one in all probability on the effect of alcohol, in the 

2 Some of the literature in this respect has been briefly analyzed by Holloway 
and myself (2). 

3 Recently Oskar Hirsch (9) in a review of the ocular symptoms in fifty-nine 
cases of tumor of the hypophysis submitted to operation (forty-five without acro- 
megaly and fourteen with acromegaly), emphasizes the fact that the lesions of the 
visual paths do not depend alone, as is usually maintained, upon the pressure of 
the growth of the chiasm, or upon the stretching of this structure, but upon its 
strangulation as the result of vascular constriction. 



172 PEKING UNION MEDICAL COLLEGE 

others there was no reason to suspect a toxic cause. Three of the 
patients died with symptoms of cerebral disease, and in one a post- 
mortem examination revealed flattening of the brain on both sides, 
and at the cerebral base a membranous sac filled with fluid lying 
on the sella turcica and extending forward to the cribriform plate 
of the ethmoid. The wall of the cyst was loosely attached to the 
hinder part of the frontal lobe, to the median part of the tempero- 
sphenoidal lobe, and to the hook of the uncinate convolution. The 
chiasm was incorporated in the front wall of the cyst. In short, as 
J. Herbert Fisher puts it, Nettleship's series of cases emphasizes the 
necessity which exists for every ophthalmic surgeon to be familiar 
with diseases of the pituitary body, especially as these scotomas may 
in a later stage develop into typical examples of bitemporal hemian- 
opsia, i.e. the field defects which are usually described as characteristic. 
In Uhthoff's (13) statistical material concerned with hypophysis 
and infundibular tumors without acromegaly, among 148 ocular de- 
fects only three "central scotomas" are noted; among those with 
acromegaly with 180 records of eye-symptoms; "central scotomas" 
are classified as "very seldom;" paracentral scotomas are not listed; 
Bartels in a total of twenty-two cases of hypophysis tumor records 
approximately only three instances of central scotoma. A. de Kleijn 
(14), although he carefully describes the variations of the visual 
field in pituitary body disease, fails to note the presence of scotomas. 
Cushing (15), in his well-known monograph, makes no reference to 
scotomas, but in his study with Clifford Walker of chiasmal lesions 
with special reference to bitemporal hemianopsia (8), they are 
carefully noted and explained, with the statement that the presence 
of these scotomas was first "described in detail" by Bartels, in Ger- 
many, and by myself and Holloway in this country (2). They have 
been, however, particularly discussed by S. E. Henschen (16), by 
H. M. Traquair (17), by Bruno Fleischer (18), and by other authors 
whose reports are scattered through recent literature. 

DEVELOPMENT OF TEMPORAL HEMIANOPSIA 

Reference has been made in the discussion of the presence of 
scotomas to the shrinking of the visual field from the temporal 
periphery, and the gradual development of hemianopsia. Frequently 



MORNING ADDRESSES 173 

this begins with a "slanting off" of the field for white of the upper 
temporal quadrant (temporal slant, J. Herbert Fisher (19)), and 
may be, and usually is, associated with a quadrantic defect of the 
color field; rarely is the condition equal in degree, that is, sym- 
metric in each field. As the result of the study of their material, 
Cushing and Walker have divided the period from the beginning 
of an advancing process to complete blindness into eight stages (8). 
Briefly, slightly modifying the description of these authors, the 
typical progress is as follows: (1) Temporal slant of field for white; 
upper, outer quadrantic color defect; relative or absolute paracen- 
tral scotoma; (2) upper temporal quadrantic defect for white; in- 
crease in temporal color defect; paracentral scotoma; (3) complete 
color hemianopsia; increasing temporal defect for white which en- 
croaches on the area below the horizontal line; paracentral scotoma; 
peripheral contraction beginning in preserved field; (4) complete 
hemianopsia for white and colors, sometimes with preservation 
of the macula; increasing density of scotoma; (5) increasing con- 
traction of the remaining field on nasal side; absolute scotoma; 

(6) shrinking of the contracting preserved nasal field from the 
vertical meridian; greatly defective or completely lost color vision; 

(7) only remaining field a small area on the nasal side; (8) blind- 
ness (Figure 16). 

The visual field alterations, just briefly described, do not, of course, 
represent observations in an individual case. As Cushing and 
Walker state (8): "These steps, or stages, have been selected out 
of the many possible ones for the reason that the larger number of 
our cases happen to have been caught in them, and not with the 
idea that the advancing process tends to halt at these separate 
stages." With this schematic series one may compare a series of 
charts from an individual case in my own practice, from the stage of 
temporal slant and paracentral scotoma to the development of com- 
plete hemianopsia (complete blindness did not occur), and grad- 
ually the return of vision and visual field function to complete 
restoration of sight and practically normal visual field extent. 
While the similarity is not exact, there is a notable correspondence 
(Figures 17 to 25). 

It is well known, as Cushing and Walker emphasize (8), that the 



174 PEKING UNION MEDICAL COLLEGE 

process, to use their language, "rarely advances with equal steps in 
the two eyes." Thus there may be an upper quadrantic defect, or a 
complete hemianopsia in one field and total darkness of the opposite 
field — a not uncommon finding; or, in advanced cases, a small 
sensitive area may be found in one field, the other being totally 
dark, which is rather sharply defined, and which can be detected 
only with the aid of a small point of electric light; or the difference 
in the extent and character of the two fields may be much less exag- 
gerated (Figures 26 to 28). 

In Traquair's (17) brilliant essay, devoted to the study of bitem- 
poral hemiopia (later stages) and the special features of the scotoma, 
and to an examination of the mechanism of production of the field de- 
fects, the conclusion is reached that in a normal or typical course of 
development of temporal hemiopia, the defect begins in the upper- 
outer quadrant, and gradually "the field is involved in a circular 
manner, the loss proceeding clockwise in the right field and counter- 
clockwise in the left, so that the upper nasal quadrant remains long- 
est." In this respect the author does not agree with the Cushing- 
Walker scheme, where the last survival of function is placed in the 
lower nasal quadrant. Traquair believes the central defect or sco- 
toma develops in the same way. Ronne holds similar views in this 
respect. 

COLOR FIELDS 

It is usually stated that the defect for colors precedes that for 
white and for form, and therefore it is proper that the color fields — 
blue, red, and green — should be carefully investigated; often the 
first color affected is green. The size of the test-object must be stated, 
because the defect (hemianopic or quadrantic) may be undetectable 
with a large-sized disc, but discoverable with a small disc. Accurate 
perimetric work cannot be done with an ordinary automatic regis- 
tering perimeter; the Bjerrum method, the campimeter, Duane's 
tangent screen and small object perimetry must be utilized. With 
these methods and these cautions, early defects can in most in- 
stances be detected in the field for white and the uncertainties and 
difficulties of color perimetry can be avoided (Figures 7 and 9). 



MORNING ADDRESSES 175 

THE DIVIDING LINE 

Although it is often asserted that in typical bitemporal hemian- 
opsia the boundary line is vertical, in point of fact, in so far as the 
hemianopsia of pituitary body disease is concerned, this line is hardly 
ever regular or vertical. Doubtless a typical vertical meridian which 
bisects the macula does occur, but if so, the opportunity of finding it 
in these circumstances is uncommon. 

INSTABILITY OF THE FIELD BOUNDARIES 

A matter of some importance which has been dwelt upon by all ob- 
servers who have carefully studied this subject, but notably insisted 
upon by A. de Kleijn (14), is the variations which the visual fields 
in some cases of pituitary body disease undergo. If daily or even 
more frequent perimetric examinations are made, a classical hemian- 
opsia may be present at one time, but later it will be found that it 
has given place to an ordinary concentric contraction. Or the re- 
verse is true; there may be a concentric contraction, due, doubtless, 
to pressure upon the peripheral optic-nerve fibers, which may even 
go on to temporary practical total loss of vision, and when the visual 
field reappears, a bitemporal hemianopsia can be demonstrated. 
De Kleijn refers to the so-called insular-shaped fields in hypophysis 
disease, these islands being subject to variations, not only in their 
number but also in relation to the part of the visual field which they 
occupy. These peculiarities in the perimetric examination doubtless 
depend upon the varying degrees of pressure of vascular and cystic 
growths in this region. 

Because of this instability or fluctuating character of visual fields 
in certain types of hypophysis disorders, an incautious observer 
may be led into error in that he accepts "an enlargement of the 
visual field" as an index of improvement of the pituitary body con- 
dition, although it may well be that alterations in the size and shape 
of the field are temporary and in no way interpret a lasting relief of 
pressure. 

HOMONYMOUS HEMIANOPSIA 

Thus far the discussion has confined itself to scotomas, usually 
paracentral and bitemporal, and with partial or complete bitem- 
poral (heteronymous) hemianopsia. While it is true that fully devel- 



176 PEKING UNION MEDICAL COLLEGE 

oped heteronymous bitemporal hemianopsia represents a visual dis- 
turbance which is regarded as typical and characteristic of affections 
of the hypophysis, it is far from true that this form of distortion of 
the field of vision is necessarily present as an ocular interpretation 
of pituitary body disorder. Referring to complete bitemporal hem- 
ianopsia, Cushing (15) writes: "Here, apparently, in many cases the 
condition lingers, and to this may possibly be attributed the fact 
that it has so long been regarded as the typical stage of the process." 
Moreover, although homonymous hemianopsia due to pressure 
upon, or lesion of, an optic tract is less common than bitemporal 
hemianopsia in these circumstances, it is not true, as has been main- 
tained, that it is "very rare" in hypophysis lesion. In common with 
other observers, I have studied a number of cases with this visual 
field defect, and Cushing has shown that these homonymous defects 
(among which, however, he includes "tendencies in this direction") 
are nearly half as frequent as bitemporal ones. This is an important 
point, because if not dwelt upon, or well understood, the presence 
of a homonymous defect in the visual field might turn attention 
away from the hypophyseal region, when in point of fact, it ought to 
be focused there 4 (Figures 29 to 32). 

RESTORATION OF THE VISUAL FIELDS 

As already pointed out, it is uncommon that the two eyes are 
affected to an equal degree, and therefore the visual field distortions 
are rarely even approximately symmetric. Should relief from pres- 
sure follow operation, or cure or improvement take place as the re- 
sult of organotherapy or radium treatment, or occur, as very occa- 
sionally happens, because of spontaneous decompression, the 
restoration of the visual field limits usually develops from below 

4 Writing in 1906, Bartels (7) says that a so-called typical hemianopsia occurs 
in only about one-third of the cases of tumor of the hypophysis where the diagno- 
sis has been confirmed by autopsy. Until the frequency of scotomas as a visual 
field defect in pituitary body disorders was recognized, their presence has, in many 
instances, led the examining physician astray in his diagnosis (20). Hirsch (9) 
records in his statistical material 7 per cent of homonymous hemianopsia. Evi- 
dently, if the growth proceeds backwards along the infundibulum, this form of 
hemianopsia would be likely to develop. Among approximately fifty clinical 
observations, I have found this defect (homonymous hemianopsia) in fully 5 per 
cent of the cases. 




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MORNING ADDRESSES 177 

upwards. This form of restoration has been admirably studied and 
depicted by Cushing and Walker (8), who state: "The recession of 
the defects (visual field defects) takes place in a sequence the re- 
verse of that which characterizes the stages of an advancing process." 
Holloway and myself (2), in our investigation of the scotomas 
which so frequently are present in the visual field (especially up and 
out) in hypophyseal lesions, were impressed with two phenomena 
related to them; namely, that during the evolution of the field defects 
they may, as it were, shift their position, and that they often "linger" 
when other field delimitations have disappeared. To this fact Cush- 
ing and Walker make reference as follows (8): "In the receding 
process relative paracentral scotomata often persist, as the functional 
vulnerability of the macular and paramacular fibres appears to be 
greater than that of the other fasciculi." 

Naturally, the earlier the relief from pressure occurs, the more 
perfect will be the restoration of vision and the fields of vision, but 
if the condition is not of too long duration, as Cushing points out, 
and as I have observed in Frazier's service, a typical hemianopsia 
may disappear; even apparent blindness, if not too long in duration, 
may be followed by return of sight, one case of this character being 
illustrated in the present series. 

DIRECT VISION 

According to the degree of pressure on the basal visual pathways 
transmitted by the hypophyseal disorder, impairment of direct 
vision may vary from blurred sight to complete blindness. In many 
cases, especially of acromegaly, abnormality in the function of 
vision is not in evidence. 

Even though vision, as estimated with the aid of test-types, is 
standard, in certain cases, probably in many of them, if the records 
were more complete, it is blurred. To this early amblyopia exact 
reference has been made in the beginning of this paper. 

Generally, as the visual field distortion progresses, the direct 
vision sinks, so that by the time the second or third stage is reached 
(Cushing and Walker's progressing temporal defect (8)), it has 
sunk to one-third or one-fourth of normal. This, however, is not al- 
ways the case; even in the presence of complete hemianopsia, where 



178 PEKING UNION MEDICAL COLLEGE 

the vertical line does not bisect the macula, and where this area is 
not covered with a scotoma, standard, or nearly standard, vision 
may obtain. But usually direct vision and its degradation maintain 
a rather close relation to indirect vision, and its increasing distortion. 
It is probable that early amblyopia is due to the vulnerability of 
the macular and perimacular bundle, which is easily insulted by 
pressure or traction, and is the last tissue of the chiasm to forget, — 
witness the persistence of paracentral scotomas during a "receding 
process." 

INTRAOCULAR OPTIC NERVE ALTERATIONS 

Visual disturbances and nerve-head changes are much more fre- 
quent in patients with primary hypopituitarism than in acromega- 
liacs, and in the majority of cases of hypophysis tumor with visual 
field defects (hemianopsia, etc.) the ophthalmoscopic appearances, 
if they are not negative, are those of so-called simple atrophy, i.e., 
partial or complete atrophic discoloration of the discs. Indeed, if the 
affection has existed for a considerable time, they are seldom absent. 
Choked disc is recorded by UhthofF (13) in 9 per cent of his collected 
cases, and optic neuritis in about the same proportion. This per- 
centage is decidedly higher than that developed by my own examina- 
tions. In the late stages, as Cushing points out, increase in the size 
of the tumor may cause increase in general cerebral pressure, with 
resulting hydrops of the ventricles and therefore disc edema, which 
may be implanted upon an atrophic nerve. This I have observed a 
few times. As we all know, internal hydrocephalus may give rise to 
symptoms closely simulating those of pituitary body disease. If the 
tumor mass surrounds and constricts the nerves, their sheaths can- 
not be distended by the cerebrospinal fluid, and edema does not take 
place. This point is made by Cushing, Traquair, and UhthofF. 

It is an important and an interesting fact that the so-called simple 
atrophy of the optic nerves, associated with tumors of the hypophy- 
sis, may present all of the ophthalmoscopic appearances of com- 
pleteness, and yet marked improvement in vision may follow a suc- 
cessful operation or prolonged organotherapy. I have studied one 
patient (1), whose optic nerves were to all appearances totally 
atrophic, with absence of light perception lasting twelve days in the 
right eye and six weeks in the left, who regained normal vision in 



MORNING ADDRESSES 179 

each eye after several months of almost constant exhibition of large 
doses of thyroid extract. Marked visual improvement may occur 
within a very short time after sellar decompression. In these pa- 
tients evidently the light impulses were blocked, but the nerve 
fibers, certainly not all of them, were not degenerated. Cushing has 
discussed this phase of the subject thoroughly, and in his laboratory 
I have studied some sections of optic nerves, stained according to 
the Weigert and Weigert-Pal method, and noted comparatively 
little degeneration, although ophthalmoscopically the nerves had 
been apparently atrophic and the visual field hemianopic. While 
prognosis must always be guarded, it would be very wrong to advise 
against operation merely because the nerve had the appearance of 
atrophy and the vision was lost or greatly degraded. 

While it may not be possible, with the ophthalmoscope, to make 
a diagnosis of so-called simple atrophy of the disc of hypophyseal 
origin, and while this variety of nerve-head discoloration sometimes 
resembles that produced by various toxic substances (the toxic 
amblyopias) and by syphilis, the papilla not infrequently presents 
an appearance which is at least suggestive. Cushing and Walker (8) 
speak of a "glistening pallor of the nerve," and in a report from the 
Mayo Foundation (21), a " peculiar waxy pallor without shrinkage," 
is referred to as "practically a diagnostic feature." 5 

The comparatively even distribution of the pallor of the nerve- 
head 6 and its somewhat waxy appearance, with a suggestion of yel- 
lowish tint, are well-recognized characteristics, and even when asso- 
ciated with paracentral scotomas and hemianopic defects, may be 
the interpretation of pressure and not of true atrophy, and represent 
the type of the condition which recovers if the pressure is perma- 
nently released. Later, should true atrophy supervene, shrinking is 
evident, and sometimes the appearances are not unlike those pro- 

6 A number of symptoms pertaining to the eyes in pituitary body disorders have 
not been discussed; the most important of these are palsy of the exterior ocular 
muscles, nystagmus, exophthalmos, visual hallucinations, chromatopsia, especial- 
ly cyanopsia, persistent photophobia, thickening and pigmentation of the eyelids, 
and hypertrophy of the palpebral glands. 

6 It is, however, true that in a number of cases the temporal side of the disc is 
paler than the nasal. Hirsch (9), indeed, maintains that the pallor of the papilla 
is regularly more pronounced on the temporal than on the nasal side. 



180 PEKING UNION MEDICAL COLLEGE 

duced by methyl alcohol. In these latter circumstances restoration 
of vision is not possible. It is always advisable to study the nerve- 
head by means of a reflecting (not electric) ophthalmoscope, and 
also by means of the indirect method, as was long ago insisted upon 
by Gowers in the investigation of color and other changes in the 
papilla. (Colored diagrams.) 

TREATMENT 

To the various forms of operative procedures performed for the 
relief of hypophyseal lesions, with the use of X-ray and radium 
therapy as an adjunct to surgical interference, or without it, I shall 
make no further reference. The discussion of this phase of the sub- 
ject is the province of the neurological surgeon. But I shall say a few 
words in regard to glandular therapy, often, it would seem, too 
optimistically recommended, and sometimes too pessimistically 
deprecated. 

In a characteristically able paper, Cushing (22) writes: ***** 
"and should he (the physician or surgeon) venture to try glandular 
therapy he must be slow to draw conclusions from the apparent 
effect of glandular extracts given by the mouth, particularly when 
more than one is given at a time ***** The experience with 
pituitary extract in diabetes insipidus shows that the substance acts 
only when given hypodermically, and we have very little evidence 
that other glandular extracts have any action when given by the 
mouth ***** Most of them (glandular extracts) contain a cer- 
tain amount of thyroid extract, which possibly is the only one of 
these substances having any definite action when given by the 
mouth." I have no intention to elaborate around these quotations a 
discussion of the value of glandular therapy either pro or con, but 
simply to restate my personal experiences in a few instances of 
dyspituitarism, elsewhere reported in detail (1). 

Case A. An unmarried white woman, aged thirty-nine, with 
tumor of the pituitary body, demonstrated by X-ray examinations, 
had complete bitemporal hemianopsia, ophthalmoscopic optic nerve 
atrophy (very pallid discs), left complete oculo-motor palsy, abso- 
lute blindness lasting twelve days in the right eye and six weeks in 
the left. Under the influence of large doses of thyroid extract, asso- 



MORNING ADDRESSES 181 

dated with inunctions of unguentum hydrargyrum, the vision of the 
right eye was completely restored and that of the left eye partly 

restored ( - ), and the hemianopsia, ocular palsy (except that of the 

ciliary muscle) entirely disappeared. Constitutional syphilis was 
not demonstrated, either by the history or by any method of exam- 
ination. During a period lasting from June i to October 3, the 
patient took 400 5-grain tablets of thyroid extract, and received 
60 i-drachm inunctions of mercury; intermittently from August 
to October, iodide of potassium was exhibited (exact dosage not 
known). During three weeks prior to beginning the thyroid feeding 
the patient had taken iodide of potassium, protiodide of mercury, 
and received a few inunctions, but none of the remedies in large doses. 
For six months after the completion of the thyroid-mercury medi- 
cation recorded above, the patient continued to take irregularly 
thyroid extract and to have mercury inunctions, but as she was not 
under my constant observation, I am unable to state accurately 
how much additional mercury and thyroid extract was adminis- 
tered. The final good result recorded was noted at the end of this 
period. No evidence of syphilis. 

Case B. An unmarried white woman, aged fifty-one, with tumor 
of the pituitary body, demonstrated by X-ray examination, had 
complete bitemporal hemianopsia (preceded by hemianopic scoto- 
mas and color hemianopsia), reduction of visual acuteness (O.D.7-, 
O.S. -^— , lowest ebb), and ophthalmoscopic optic disc atrophy; no 

muscle palsies. During a period lasting from June 10, 19 14 to Decem- 
ber 10, 1914, she took 400 a|-grain tablets of thyroid extract, and 
200 2|-grain tablets of pituitary body extract, and received 58 
i-drachm inunctions of unguentum hydrargyrum. Vision of O.D. 

now — , but vision of O.S. reduced from — at first examination 
7-5 12 

4 . . . 

to . Thyroid-pituitary body extract was continued, but no more 

mercury given. From July, 19 14 to February, 19 17, she consumed 
2,100 tablets (2J grains each) of thyroid extract and of pituitary 
body extract, because, although vision was practically restored nearly 



1 82 PEKING UNION MEDICAL COLLEGE 

two years before, if these medicines were discontinued, headache 
returned. No history of syphilis and none was demonstrated by 
laboratory tests. 

Case C. An unmarried woman, aged eighteen, with tumor of the 
pituitary body, not absolutely demonstrated by X-ray examination, 
in that the report was "sella ill-defined and cloudy," with periods of 
diplopia for at least a year, moderate choking of each disc (2.5 D.). 
When examined complete blindness of the right eye (lasting one 
week), and vision of left eye reduced to counting fingers in the tem- 
poral field, the nasal field being entirely dark, but the temporal field 
for form intact. At the expiration of forty days of active medication, 
during which time she took 200 grains of thyroid extract, and re- 
ceived 30 i-drachm inunctions of mercury, vision was restored, 

( — each eye, — both eyes ), the choked discs had disappeared, the 

surfaces of the discs being pale, and the visual fields normal. History 
and laboratory tests negative in so far as syphilis was concerned. 

A number of reports are on record of the relief of the symptoms of 
hypophyseal disorder as the result of glandular therapy (Elsberg, 
Timme, and others in America, as well as physicians abroad), or at 
least improvement was coincident with the administration of 
glandular extracts. Two of the patients whose histories are sum- 
marized were unquestionably the subjects of dyspituitarism; in one 
of them the interpretation of the signs is not quite clear, and the 
case may be omitted from further consideration. Each of the patients 
selected received, in addition, in the one instance to thyroid extract 
alone, and in the other to thyroid and pituitary body extract, large 
doses of mercury by inunction; neither of them, if laboratory tests 
and clinical history can be trusted, was a syphilitic subject. In each 
the cure was perfect and has remained so for a number of years. 
What the influence of mercury was in these cases, (assuming, as I 
think it is proper to assume, that the patients were not luetic), I do 
not know, — an increase of the so-called antiphlogistic action of 
mercury by virtue of the action of the gland extracts, a synergic 
action in that the mercury and extracts aid each other in stimulat- 
ing glandular secretion, with advantage, therefore, in conditions of 
glandular insufficiency, have been suggested. Timme (23) believes 



MORNING ADDRESSES 183 

that thyroid administration enhances the effects of specific treat- 
ment; but there is no reason to believe that either of these patients 
was syphilitic. 

All that I can say is, and on this I insist, that in any case of estab- 
lished or suspected disorder of the pituitary body the patient should 
be studied by the neurologist, the surgeon, the ophthalmologist, and 
the roentgenologist. As the result of such a conference the meas- 
ures of relief must be decided. If operation is declined (as it was by 
both of the patients described), glandular therapy should certainly 
be tried, and if my limited experience, but none the less happy one 
in these instances, is worth anything, mercury should be added to 
the treatment. It is hardly necessary to say that in other cases I 
have tried these combinations without beneficial results. 

CONCLUSIONS 

The chief object of this paper, in addition to its effort to bring 
into review the evolution of some of the most prominent ocular 
symptoms of pituitary body disorders, concerns itself with an at- 
tempt to establish an early diagnosis, that is, before serious visual 
degradation develops. 

It is surprising, to quote Charles H. Frazier (24), how late in the 
course of the disease the true nature is revealed. This surgeon, in 
looking over his records, found that when he was first consulted, 45 
per cent of the patients had practically or entirely lost the sight of 
one eye, and that 6.5 per cent of the patients were totally, or nearly, 
blind in both eyes. In many of these instances had the patients come 
in early periods of their difficulties, there is no question that sight 
could have been saved. 

A large number of patients with hypophyseal lesions first consult 
the ophthalmologist because their conspicuous symptoms are ocu- 
lar, but unhappily, wait only too often until field distortions and 
disc-pallor or atrophy are far advanced. Fortunately, in compara- 
tively recent times pituitary headaches are coming in for a share of 
attention which they richly deserve, and if the suspects are carefully 
examined (vision, fields, X-ray, etc.), future statistical groupings 
will contain the records of early cases, and the degradation of vision 
will be prevented. 



i8 4 PEKING UNION MEDICAL COLLEGE 

It is probable, certain notable conditions excepted, that a definite 
period of time must elapse before a hypophysis lesion causes defec- 
tive vision, disc-pallor and gross visual field changes, — ■ perhaps 
several months. But I am well persuaded that the early amblyopia 
to which I have several times referred is destined to be more often 
recognized, and I am further persuaded that proper field examina- 
tions by modern methods are sure to detect pituitary body affec- 
tions which have only too frequently escaped recognition until the 
grosser defects have developed. 

Cushing and Walker (8), in their well-known paper, which has 
so frequently been quoted, say. "Detailed perimetry with small test 
objects of serial sizes, particular attention being paid to the shading 
off of the upper temporal peripheries and to the presence of relative 
paracentral scotomata in the same quadrant, is advocated for pa- 
tients with pituitary disease in order that stages of hemianopsia 
antecedent to those usually recognized may be detected." 

To this I would add that patients with persistent headache, unre- 
lieved by optical therapeutics, or unexplained by definite nasal, 
gastric, toxic, or systemic conditions, must be subjected to "detailed 
perimetry with small test objects," and to X-ray examination. 
Many years ago, at the instance of Weir Mitchell, I investigated all 
of his patients coming to the Infirmary for Nervous Diseases in 
Philadelphia with what it was the custom to call "chronic head- 
ache," with the aid of a perimeter, and found visual field changes. 
But the findings were not correctly interpreted, and the methods 
were comparatively crude. Doubtless in a number of these cases 
pituitary involvement was overlooked, as well as other conditions 
creating increased intracranial pressure. Now our methods of exam- 
ination are greatly improved and our technique largely refined. 
What is necessary is to insist upon a more general use of these 
methods and the employment of this technique. 

BIBLIOGRAPHY 

i. De Schweinitz, G. E., Penn. M. J., 1911-12, xv, 515. 

1. De Schweinitz, G. E., and Holloway, T. B., J.Am. M. Assn., 1912, lix, 1041. 

3. De Schweinitz, G. E., Tr. Coll. of Phys. Pbila., 191 5, xxxvii, 98. 

4. De Schweinitz, G. E., and How, H. W., Arch, of Ophth., 1917, xlvi, 139. 

5. De Schweinitz, G. E., Arch, of Ophth., 1921, 1, 203. 



MORNING ADDRESSES 185 

6. Doyne, R. W., Tr. Opbtb. Soc. U. Kingdom, 1895, xv, 133. 

7. Bartels, M., Ztschr.f. Augenb., 1906, xvi, 428. 

8. Cushing, H., and Walker, C. B., Brain, 1914-15, xxxvii, 341. 

9. Hirsch, O., Ztscbr.,f. Augenb., 1921, xlv, 294. 

10. Foerster, Graefe-Saemisch Handb. d. ges. Augenb., 1st edition, 1877, vii, 1 16. 

11. Miiller, D. E., Arch.f. Opbtb., 1861, viii, 160. 

12. Nettleship, E., Opbtb. Rev., 1896, xv, 309. 

13. Uhthoff, Tr. Opbtb. Soc. U. Kingdom, 1914, xxxiv, 226. 

14. De Kleijn, A., Arch.f. Opbtb., 191 1, lxxx, 307. 

15. Cushing, H., The Pituitary Body and Its Disorders, Philadelphia and 

London, 1912. 

16. Henschen, S. E., in Lewandowsky, M., Handb. d. Neurol., 1912, iii, 757. 

17. Traquair, H. M., Brit. J. Opbtb., 1917, i, 216, 281, 337. 

18. Fleischer, B., Klin. Monatsbl.f. Augenb., 1914, lii, 625. 

19. Fisher, J. Herbert, Tr. Opbtb. Soc. U. Kingdom, 1911, xxxi, 51. 
^20. Hecht, D'O., J. Am. M. Assn., 1909, liii, 1001. 

21. Benedict, W. L., Am. J. Opbtb., 1920, iii, 571. 

22. Cushing, H., J. Am. M. Assn., 1921, lxxvi, 1721. 

23. Timme, W., Arch, of Ophth., 1921, 1, 271. 

24. Frazier, C. H., Arch, of Ophth., 1921, 1, 217. 



PLAGUE IN THE ORIENT WITH SPECIAL REFERENCE 
TO THE MANCHURIAN OUTBREAKS 

By 

Wu Lien Teh, M.D. 

INTRODUCTION 

Plague is essentially an Oriental disease, and whether Dr. W. J. 
Simpson is right or wrong in naming China's southwestern province 
of Yunnan as its primary focus of infection, there is no doubt that 
since the great pandemic of 1 894 the endemic areas have increased 
both in number and extent. The vast Empire of India with its 320,- 
000,000 people may be considered permanently infected, although 
certain administrative areas like the Punjab, the Presidency of 
Bombay, and the United Provinces of Agra and Oudh suffer to a 
greater extent than the hilly province of Assam, where during the 
last six years only one case has been recorded. During the last 
eighteen years, over ten million persons have died of plague in 
India alone. In other parts of Asia frequent outbreaks of plague 
have occurred during recent years, e.g., Ceylon, Straits Settlements, 
Dutch East Indies, Siam, Indo-China, Japan, Hongkong, the 
provinces of Kwangtung and Fukien (particularly at the ports of 
Canton, Swatow, Amoy, Foochow), Manchuria, and Siberia. The 
coal mining center of Tongshan three hours by rail from Tientsin 
was infected by some bubonic cases from Hongkong in 1898 and lost 
a thousand lives in four months. The port of Newchwang (Yinkow) 
in South Manchuria was invaded in 1899 (probably through vessels 
from the south) and lost in five months 2,000 people. From 1901 to 
1903 isolated cases were detected, but they never resulted in an 
epidemic. It is strange that the great pulmonary epidemics of 191 1 
and 1921 did not touch either Tongshan or Yinkow, although both 
lie on the main highway of railway traffic. 

Although favorable results have been obtained by the application 
of modern preventive methods in such places as the Philippines and 
Japan, the total suppression of bubonic plague appears to be an 
ideal still to be achieved by interested governments. The following 

186 



MORNING ADDRESSES 



187 



mortality figures show how widespread the disease is in different 
parts of the Orient (Table 1). 

Passing on to China, we find that statistics are difficult to obtain 
from any part except Shanghai and Manchuria, the former con- 
trolled by an efficient Health Department of the International 
Municipal Council, the other by the Manchurian Plague Prevention 
Service. Shanghai with a population of close to a million reported 

table 1 
Plague Invaded Areas in the Orient 



Location 



India 

Ceylon 

Straits Settlements . 
Dutch East Indies 

Siam 

Indo-China (French) 

Hongkong 

Japan 

Formosa (Japan) . . 



Years 



1896-1917 
1914-1917 
I910-I917 
I9II-I917 
I9II-1917 
I9U-1917 
1895-1917 
I907-I916 
1896-1917 



Year of 
Severest 
Infection 



1907 
1914 
1917 
1917 
1916 

!9 J 3 
1914 

1907 

1 901 



Total 
Plague 
Deaths 



9,841,396 
978 
280 

34,73 2 

1,063 

14,911 

15.731 

1,380 
24,108 



Aggregate 
Population 



320,000,000 

800,000 

1,000,000 

40,000,000 

9,000,000 

18,000,000 

520,000 

50,000,000 

3,400,000 



only sixty-one human cases and 1,108 infected rats in the years 
1910-19. The years 1916-19 were entirely clear. 

In the two southern provinces of Kwangtung and Fukien, epi- 
demics of greater or less severity occur almost yearly, but up to the 
present no reliable records have been published. It is hoped that 
with the recent establishment of a Ministry of Health attached to 
the Southern Government, headed by a responsible medical man, 
we may look forward to more accurate information during the 
coming years. 

The incidence of plague in a country or community seems to de- 
pend as much upon its location, climate, humidity, and the character 
of its inhabitants, as upon the preventive measures employed. For 
instance, as far as India is concerned, the mortality curve reaches 
its highest point in March and its lowest in July. This periodicity 



1 88 PEKING UNION MEDICAL COLLEGE 

has been demonstrated to be due to the humidity of the earlier 
months of the year, since humidity is favorable to the life of the flea. 
In spite of the efforts of the government to deal with native preju- 
dice, and the well-directed measures to control the malady, it has 
continued to rage from year to year with almost unabated severity 
up to the present time. On the other hand, we see steamer traffic 
taking place regularly between the endemic southern ports of Can- 
ton, Hongkong, etc., and northern ports like Shanghai, Dairen, 
Chefoo, Tientsin, Newchwang. Yet plague seldom visits these places, 
although there must be large numbers of infected rats in the holds 
of the steamers, and ordinary anti-rat precautions such as disc 
guards and tarred ropes are not rigidly enforced when these ships 
are moored beside the wharves. 

With the exception of some accidental cases, the epidemics re- 
ferred to above have been of a bubonic nature, propagated by means 
of and through the agency of the rat flea. As found in India, when- 
ever the seasons are most humid, fleas abound and the incidence of 
bubonic plague becomes greater. The prevention of plague in these 
regions therefore lies principally in the destruction of rats, the rat- 
proofing of houses, and the proper supervision of possible rat-in- 
fested merchandise, especially grain, which certain authorities re- 
gard as more dangerous vehicles of infection than human beings. 

THE MANCHURIAN OUTBREAKS 

When we turn to the series of epidemics known as the Manchurian 
outbreaks, we deal clinically and epidemiologically (except that the 
causative organism is the same) with a totally different disease. In 
this type of plague the role played by the rat and its appendage the 
flea is negligible, beyond the fact that the early cases are probably 
secondary manifestations of the bubonic infection in the lungs, 
which in a favorable environment, such as is met with in the crowded 
semi-underground inns of North Manchuria, readily follows a 
purely pulmonary course. It is quite possible that the tarabagan or 
Mongolian marmot (Arctomys bobac), found in large numbers on the 
Siberian and Mongolian plains, may, like the domestic rat, harbor 
the plague organism and that it is the real precursor of epidemics of 
plague pneumonia. Our latest experiments on these animals, which 



MORNING ADDRESSES 189 

will be mentioned later, seem to support this view. So able an ob- 
server as G. W. McCoy (1) has stated, "Pneumonic plague in 
man rarely occurs from rat infections, and it is an interesting and 
possibly significant fact that in plague squirrels there is a very defi- 
nite tendency to pulmonary localization, a condition which never 
occurs in plague in rats." 1 

Russian observers have steadily clung to the idea that plague 
arises from the skinning and eating of tarabagan flesh, so that when- 
ever a case is reported in Siberia, the comment, "after having par- 
taken of the flesh of tarabagan," inevitably follows. At the time of 
writing (August 20, 1921), some new cases of bubonic plague have 
just been reported from Dauria in the Transbaikal regions, the first 
two being a Russian station master and a signal man, who respec- 
tively developed a cervical and an axillary bubo after having skinned 
and eaten tarabagan flesh. Careful inquiries made by our medical 
officer on the spot have elicited the information that these two men 
skinned as well as ate the flesh while four others who only ate the 
flesh did not fall ill. Three more cases have been reported in that 
region, including a doctor who operated on the bubo of the station 
master and developed plague septicemia. It will be interesting to see 
whether any pulmonary cases will result from this* local outbreak, 
as we may then have some ground for connecting the tarabagan 
with pneumonic plague in man. My own researches in Mongolia in 
1912 failed to record a single authentic case of direct tarabagan in- 
fection in man, and until further evidence is produced one is obliged 
to come to the conclusion that the Manchurian epidemics have 
arisen as a result of primary bubonic infection invading the lungs in 
addition to other organs. Whether the wild tarabagan or the domes- 
tic rat plays the more important role in disseminating the disease in 
this endemic region must still be worked out, and it must be confessed 
that our attempts at finding infected rats in Manchouli, Hailar, 
Harbin, and Mukden (all situated in Manchuria) have been as devoid 

1 This statement will require modification in view of some interesting localized 
pneumonic-plague epidemics recorded: e. g., British freight steamer, Friary, which 
had eight deaths out of a crew of twenty-one in 1901; British mail steamer, 
Nagoya, which had eight deaths out of a crew of 195 in 191 9; two epidemics on 
the Gold Coast in 1908 and 1917, and others (2 and 3). 



[90 



PEKING UNION MEDICAL COLLEGE 



of positive results as our attempts to find plague infected marmots 
in their underground quarries in Mongolia. 

That the Transbaikal region is endemic for plague may be judged 
from Table 1. Several years ago (4) I made a summary covering the 
period 1898-1910, showing that plague occurred every year in the 
Kirghiz Steppes, a vast stretch of territory extending from Astra- 
khan in Europe to Uralsk and Semiretchinsk in Asia. 

It will be seen from Table 2 that the three great epidemics oc- 



TABLE 1 

Plague Tears in Siberia and Manchuria 







Locality Where 






Year 


Season 


Plague Was 
Present 


Type 


Mortality 


1910 


Sept. 


Dauria (Siberia) 


Bubonic and pneu- 
monic 


40 


1911 


Oct.-Apr. 


Manchuria and N. 
China 


Pneumonic 


60,000 


1912 




No record 






l 9 l 3 


Aug. 


Kirghiz Steppes 


Bubonic 


Not ascertainable 


1914 


Oct. 


Transbaikalia 


Bubonic 


13 (out of 16) 


1915 




No report 






1916 


Sept.-Oct. 


T'aochow in Kansu 


Pneumonic 


About 60 


1917 


Sept.-Dec. 


South Mongolia 


Bubonic and pneu- 
monic 


Not ascertainable 


1918 


Jan. -Apr. 


8 provinces: S. Mon- 
golia, Suiyuan, Cha- 
har, Shansi, Chihli, 
Shantung, Anhwei, 
Kiangsu (offshoot 










of 1917) 


Pneumonic 


16,000 


1919 


Sept. 


Ikievkaya (Trans- 










baikalia) 


Bubonic 


2 


1920 


Sept. 


Abagatui (Transbai- 










kalia) 


Bubonic 


5 (out of 6 cases) 


1921 


Jan.-May 


N. Manchuria, 










Chihli, and Shan- 


Pneumonic chiefly, 


9,000 






tung (offshoot of 


only 12 bubonic 








above) 


cases observed 




1921 


Aug. 


Dauria, 40 miles 










west of Manchouli 


Bubonic 


5 (so far) 



MORNING ADDRESSES 191 

curred in 1910-11, 1917-18, and 1920-21, when 60,000, 16,000, and 
9,000 persons, respectively, died. As I was directly responsible for 
the antiplague work in the first and third epidemics, I will deal with 
them fully here. The first epidemic found China absolutely unpre- 
pared, for until our staff arrived there were no hospitals and no 
proper sanitary staff to cope with the emergency. The Central 
Government had, however, considerable power over the provinces, 
and when I applied for the necessary funds, medical assistance, and 
permission to perform postmortems, and to cremate the dead, all my 
requests were rapidly granted, and by April, 1 9 1 1 , the whole epidemic 
from Harbin southwards as far as Shantung had been stamped out. 
When the 1920-21 outbreak came we were much better prepared. 
The Manchurian Plague Prevention Service had been established 
for nine years, and the officials and natives more or less understood 
the nature of our mission, so that, although some trouble was caused 
by unruly soldiers and the ignorant masses led by a few professional 
agitators, our antiplague measures met with general approval. Only- 
four cities reported a high mortality (Manchouli, Dalainor, Tsit- 
sikar, and Harbin), claiming 7,000 out of the total 8,500 deaths in 
Manchuria. The epidemic was confined to North Manchuria, prac- 
tically all places south of Changchun escaped, and only 300 cases 
occurred in the two provinces of Chihli and Shantung. 

Table 3 gives a comparison of the two epidemics showing the 
date of the first case reported and total mortality in each district. 

As illustrating how the migration of the population affects the 
spread of the disease, two points may be stated. (1) In the 1910-11 
epidemic there was no definite antiplague authority and no co-op- 
eration between the various railway lines operating in these areas. 
Sick patients and persons incubating the disease spread the infec- 
tion broadcast, and thousands of victims were reported in all of the 
large cities between Harbin and Tsinan (Shantung). It was quite 
common to find a dozen cases in the trains on the South Manchurian 
and Peking-Mukden lines. One notorious train conveying thirty- 
nine sick to Tientsin and Peking was sent back to Mukden, and it 
was the sorting out of these cases that probably caused the death of 
the young Englishman, Dr. Jackson. In 1921 we made timely ar- 
rangements with the railway authorities regarding the restriction 



192 



PEKING UNION MEDICAL COLLEGE 



TABLE 3 

Two Epidemics Compared 



City 



Dauria (Siberia) 
Abagatui (Siberia) 
Manchouli . . . 
Dalainor .... 

Hailar 

Tsitsikar .... 
Harbin .... 

Hulan 

Shwangchengpu . 
Changchun . . . 
Kungchuling . . 
Mukden .... 

Dairen 

Chefoo .... 
Tsinan .... 
Vladivostok . . 



1910-n 



First Case 


Total 


First Case 


Total 


Reported 


Mortality 


Reported 


Mortality 


Sept. 


40 










Sept. 


5 


Sept. 


400 


Jan. 21 


1,141 


Oct. 19 


120 


Jan. 13 


1,047 


Oct. 27 


3 


Oct. 22 


98 


Dec. 4 


600 


Jan. 18 


i,734 


Oct. 27 


9,000 


Jan. 22 


3, I2 5 


Dec. 13 


4,000 


Feb. 7 


322 


Jan. 5 


1,500 


Mar. 14 


134 


Dec. 31 


t;,ooo 


Jan. 31 


77 


Jan. 15 


35 


Jan. 31 


5 


Jan. 4 


4,500 


Mar. 29 


4 


Jan. 4 


66 







Jan. 21 


400 


May 3 


24 


Feb. 1-7 


450 












Apr. 9 


520 



1920-21 



and control of the passenger traffic and so saved thousands of lives. 
(2) In 191 1 very few coolies traveled eastward from Harbin to Sui- 
fenho and Vladivostok;, and hence no cases were reported at either 
place. In 1921, however, owing to the opium boom, 800 to 1,000 
third and fourth class passengers were traveling in that direction 
daily to cultivate the fertile regions. Although the inspection of 
passengers was enforced at Harbin station, several persons incubat- 
ing the disease escaped detection and developed symptoms on 
arrival at different towns. Fortunately, these were isolated instances, 
and only Vladivostok suffered to any great extent, claiming 520 
deaths up to July, among them two bubonic cases. Some infections 
among rats were also found. 

SEASONAL PREVALENCE 

When we study the seasonal prevalence of the epidemic, we find 
that on both occasions it originated in September (the one at Dauria 



MORNING ADDRESSES 193 

and the other at Abagatui, two Siberian villages). The first outbreak 
continued without any interruption at Manchouli and passed on to 
the other cities until its suppression in the following April. The 
second outbreak did not show its full virulence until November, at 
Hailar, where I personally examined the early bubonic cases and saw 
the gradual evolution through the septicemic into the pulmonary 
form. It was the liberation of nine contacts by the local soldiers 
after their attack upon the Chief of Police and the escape of some to 
Dalainor that led eventually to the general epidemic; for in the 
windowless, insanitary, underground dwellings of the miners, forty 
to sixty of whom were herded together in double tiers within an 
area of 40 by 20 feet, the Bacillus pestis found indeed a fruitful soil. 
From Dalainor cases traveled to Manchouli, Tsitsikar, and Harbin, 
where strong measures had been taken to protect both the local 
people and places further south by means of the inspection of trains 
as well as by quarantine of the restricted number of third class 
passengers for five days at Changchun. The poorer members of the 
community, however, did not understand the value of preventive 
measures and refused to report cases. When anyone fell ill he was 
hidden until dead and then thrown out into the street at night, or 
else he was driven out in the last stages of the disease, with the in- 
junction not to report his address, for fear the contacts would be 
sent to the observation wagons. This unnecessary fear of the anti- 
plague officers extended even to the educated classes, for one of the 
corpses picked up in the streets was identified as that of the Vice 
Chairman of the native medical society whose wife preferred this 
treatment of her dead spouse to being isolated. 

SOME PROMINENT SYMPTOMS. DANGER TO CONTACTS 

It is not my purpose in this address to travel over old ground but 
to allude to the more interesting and rarer features of the disease. 
Like other insufficiently studied affections, pneumonic plague grips 
the interest of the research worker, not only because of its extraor- 
dinary virulence, its simple direct means of infection, and its equally 
simple method of control (if only the human machine were not such 
a complex psychological and obstinate factor), but also because of 
the possibilities of immunization. 



194 



PEKING UNION MEDICAL COLLEGE 



After an incubation period of two to six, usually three days, the 
patient feels drowsy and dizzy, with headache and lack of appetite. 
He complains of a chilly feeling and develops a moderate tempera- 
ture of 102 to 103° F., and fast, soft pulse. This condition usually 
lasts for twenty-four hours before a cough sets in, at first dry but 
quickly accompanied by liquid, frothy sputum tinged with bright 
red blood. In a fair percentage of cases the hemorrhage is consid- 
erable, the floor and bedding being profusely covered with blood; 
while occasionally the patients die without experiencing any cough 
or hemoptysis. The period intervening between the appearance of 
the fever and the first sign of cough is most important for those in 
charge of contacts, because this is the non-infective interval when 
the sick may be removed without endangering the others. As soon as 
cough appears the danger of infection becomes greater. This is well 
illustrated in the case of our late Dr. Yuan Teh-mao, who was in- 
fected while serving as chief of the house-to-house inspection squads. 
On the fifth day after exposure, though feeling ill and probably 
feverish, he still attended a crowded sanitary conference of twenty- 
six people and moved among our medical staff the whole day. 
That night he was sent to bed with a temperature of 102° F., and 
the next morning Bacillus pestis was found in the scanty sputum 
coughed up. Not one of the sixty persons with whom he had mingled 
became ill. Table 4, illustrating the percentage of plague cases 
among contacts confined in our isolation cars at Harbin, shows how 
small a percentage develop the disease if properly cared for. Inci- 



table 4 
Mortality among Contacts in Isolation Wagons 



Month 


No. Admitted 


Sent to 
Hospital 


Plague 


Non- 
Plague 


Per Cent 
Plague 


Feb. .;.... 
May 


547 
911 

485 
78 


47 
118 

57 
5 


34 
92 

47 
5 


J 3 
26 

10 




6.2 
IO. I 

9-7 
6. 4 


Total in 4 months. 


2,021 


3 2 7 


178 


49 


8.1 
(Average) 



MORNING ADDRESSES 195 

dentally, it points out that during the height of the epidemic (March 
and April), when the assistants were dealing with an unusual num- 
ber of contacts, the percentage of infection was higher. 

These figures compare very favorably with those of Dalainor, 
where, owing to incomplete organization and the obstinacy and dis- 
obedience of the mining coolies, 144 out of 655 contacts registered in 
February and March, i.e., 21.8 per cent, died of plague. 

PLAGUE CARRIERS 

In discussing such a deadly infection as pneumonic plague the 
question of carriers naturally invited our attention. The discovery 
of the first authentic case was accidentally made when dealing with 
the first group of contacts. 

Chang I, aged twenty-seven, motor car driver, was admitted to 
Harbin Isolation Ward on February 1, with nineteen other persons 
from an inn where one man had died of plague. On February 2, he 
complained of headache and slight fever. Sputum, apparently nor- 
mal, showed suspicious bacilli the same day. Cultures examined the 
next day were positive and the majority of the bacteria resembled 
Bacillus pestis. On February 7, this positive culture (whole agar 
slope) was inoculated intraperitoneally into a guinea pig. Eighteen 
hours afterwards the guinea pig died, and smears from heart, spleen, 
and peritoneum showed Bacillus pestis. Cultures from same organs 
all showed pure Bacillus pestis. On February 6, after the patient had 
been apparently well for four days, swabs were taken from his spu- 
tum and tonsils. Culture from sputum was inoculated into a guinea 
pig, which died twenty-four hours afterwards. Smears and cultures 
from spleen, heart, and peritoneum gave positive results. 

One of the eighteen contacts, Wang, died unexpectedly on the 
evening of February 6, i.e., six days after his last contact with the first 
sick man. As the incubation period of pneumonic plague is seldom 
over five days, it is possible that Wang might have been infected 
by the carrier Chang who harbored the bacilli for at least a week. 

After this event, twenty-four other examinations were made for 
possible carriers between March 1 and 30, but in only one instance 
did we obtain positive results. 

Chang II, aged thirty, coolie, was one of four contacts examined 



196 PEKING UNION MEDICAL COLLEGE 

on March 4. Sputum appeared normal and cultures were made. 
Growth forty-eight hours after showed suspicious bacilli. On March 
6 this was inoculated subcutaneously into a guinea pig, which died 
twenty-four hours afterwards. Smears from heart, spleen, and lungs 
were all negative, but cultures from the heart showed several colo- 
nies, and those from the spleen, one colony. Another guinea pig inocu- 
lated intraperitoneally with this heart culture died in twenty-four 
hours with positive findings in heart, spleen, and peritoneum. 

One girl examined on March 16 also showed Bacillus pestis, but 
she developed the disease before the end of the incubation period 
and her case was therefore disregarded. 

It is premature to say how far the question of carriers influences 
the course of a pneumonic plague epidemic but this is the first occa- 
sion on which the matter had been scientifically worked out and 
confirmed. 

INFECTIVITY OF SICK ROOMS 

The illness of Dr. Yuan from February 17 to 20 in our new hos- 
pital block (steam heated, with temperature maintained at 17° C.) 
enabled us to make the first investigation regarding the infectivity 
of the sick room per se immediately after the death of the patient. 
For this purpose the following experiments were made: 

Twelve guinea pigs, two each in tin buckets, were placed on the 
wooden floor of the room (12 by 12 by 10 feet, with one large closed 
window) for periods ranging from one-half to four hours. Nothing 
was previously disturbed and the door was not opened except when 
the animals were removed at certain times. Only two guinea pigs 
died; the first had been exposed for one hour, dying on the fourth 
day, and the second had stayed in the room half an hour, dying on 
the seventh day. The other ten remained healthy. Postmortems con- 
firmed septicemic plague with congestion of lungs in both animals. 

Eight guinea pigs in lots of two were exposed on March 2 to air of 
sick room, one-half hour before, one-half hour after, one hour, and 
two hours after death of patient. One animal died on March 17 (i.e., 
fifteen days after exposure), showing no bacilli on smears of organs, 
though pure cultures from the blood were obtained. 

Four guinea pigs were allowed to stay in the plague room from 
April 5 to 9, where six patients had successively come in and died. 



MORNING ADDRESSES 197 

One animal became sick, and on being killed showed lesions in the 
respiratory organs. No tonsillar or glandular infection was noticed. 
This experiment was performed on behalf of a Russian bacteriolo- 
gist who at first believed the primary seat of infection was situated 
in the tonsils. 

Seven other experiments were performed with ten rabbits and 
twenty-eight guinea pigs by placing them in sick rooms both before 
and after the patients had died, and also in coffins containing clothes 
freshly removed from the dead, but in no case did the animal die. 
One rabbit showed pneumococcal infection. Similar experiments 
were also conducted at my request in March at Dalainor by Dr. 
E. T. Hsieh, who exposed ten young rabbits at heights varying from 
1 to 8 feet to the air of a room (10 by 12 feet) recently vacated by 
four dead. The animals were all living on the seventh day and 
afterwards. 

These discoveries seem to indicate that the sick room by itself or 
even when occupied by plague patients is not particularly dangerous 
except when one is standing in the direct line of the sputum or drop- 
let. They also raise the question as to the need of spending so much 
energy and money on the disinfection of houses, as well as the wis- 
dom of burning infected quarters, which was done so extensively in 
the 1910-11 epidemic. 

INFECTIVITY OF RAILWAY CARS 

We have on record four occasions on which a plague patient 
suffering from fever and cough was found in a crowded railway car 
running between Harbin and Changchun. The first was on February 
2, when a dying man with hemoptysis was discovered at Yaomen in 
the train leaving Changchun for Harbin. The other forty-seven pas- 
sengers were forthwith conveyed to Harbin for observation but all 
remained healthy and after six days were liberated. The next two 
happened on February 16 and 20, when thirty-seven and forty- 
seven persons were similarly observed without subsequent illness. 
The fourth case occurred in the middle of March, and here also 
none of the thirty contacts developed the disease though all had 
been in the car with the sick man for over nine hours. The distance 
between the two cities is 150 miles. 



198 PEKING UNION MEDICAL COLLEGE 

EFFICACY OF GAUZE AND COTTON MASKS 

It has been pointed out by Barber and Teague (5) that the simple 
gauze and cotton mask introduced by me and recommended by the 
International Medical Conference of Mukden in 191 1 for pneumonic 
plague work is pervious to a spray of Bacillus prodigiosus. Dr. J. W. 
H. Chun working with Bacillus lactis obtained similar results. It 
must, however, be remembered that in the plague wards one does 
not stand within a distance of three feet in the direct line of the 
breath of the patient, and that quiet breathing or an occasional 
cough is unlike the continuous spray used in the experiments. 

To satisfy ourselves further, we made a series of cultures from 
masks which had been used in the wards by the doctors and assist- 
ants tor various periods ranging from one-half to four hours. The 
outer gauze layer, the inner gauze layer, and the intervening cotton 
wool were all tried. In only one sample out of fifteen investigated 
was a positive culture obtained, namely from the outer layer of the 
gauze which had been worn continuously for three hours. Neverthe- 
less, in view of Dr. Yuan's accident, we considered it best to adopt 
besides the mask a new precautionary measure in the form of a hood 
made of cloth with a square piece of silk (4 by 6 inches) sewed on in 
front to protect the respiratory entrance. This hood had two aper- 
tures for the eyes and was tucked inside the overall at the neck. 
With the exception of Dr. Yuan, none of our physicians or dressers, 
numbering over eighty, met with mishap. 

EXPERIMENTS UPON SPUTUM OF PATIENTS 

Many experiments were made upon the sputum of patients and 
dealt with the action of direct sunlight, indirect sunlight, drying 
under different conditions, sulphur fumes, formalin vapor, and over 
a dozen kinds of antiseptics and disinfectants upon the fresh sputum. 
A detailed list of our findings would consume too much time. 
Suffice it to say that in at least four samples of sputum exposed in 
bulk on a petri dish to the sun for two to six hours till they appeared 
dry to the naked eye we could still cultivate the Bacillus pestis by 
scraping the remainder. 

With regard to fumigation we found that one average specimen 
of plague sputum placed in a petri dish in a room measuring 10 by 



MORNING ADDRESSES i 99 

10 by 10 feet was more favorably acted upon by sulphur fumes than 
by formalin vapor. Out of seventeen observations made upon the 
former with exposures varying from four to twenty- four hours we 
could grow the Bacillus pestis on only one occasion (four hours). 
Out of twenty observations upon formalin vapor, we obtained cul- 
tures in eight cases (four to twenty-four hours). Light clothes and 
overalls, owing to their porous nature, were quickly sterilized by 
formalin vapor, hence formalin gas was generally used for overalls, 
alcohol for hands and gloves, while moist sulphur dioxide was em- 
ployed for the fumigation of houses. 

A large number of experiments have in the past been performed 
upon cultures of Bacillus pestis, but so far as we know this is the 
first time that a systematic attempt has been made to test the effi- 
cacy of antiseptics and disinfectants upon the actual plague sputum. 
The following experiments were made: 

EFFECTS OF DISINFECTANTS UPON SPUTUM 

Experiment A. Small cotton swabs mounted on iron wires were 
placed in test-tubes and sterilized by dry heat. Five cc. of fresh 
solutions of the antiseptic in different strengths were placed inside 
each tube. At the proper moment the swab was dipped into the 
sputum in a petri dish, suspended in the antiseptic solution for the 
requisite number of minutes, and then washed in sterile normal 
saline solution to remove excess of antiseptic. After this, the swab 
was introduced into a fresh agar tube and a culture made. The same 
procedure was repeated with the other solutions, care being taken 
to allow for as little discrepancy as possible in the quantity of 
sputum tested. The cultures were examined as a rule after forty- 
eight hours in the incubator kept at 30 C. 

In this way 433 observations were made extending over a period 
of two months. The chemicals used were carbolic acid, mercuric 
perchloride, lysol, izal, phenol, potassium permanganate, hydrogen 
peroxide, lysoform, antiformin, rectified alcohol, methyl alcohol, 
lime-water, and slaked-lime. The time of immersion varied from one 
minute in the case of alcohol to thirty minutes in the case of anti- 
septic solutions. Our findings were rather surprising. For instance, 
in the case of carbolic acid, a solution of only 10 per cent for five 



aoo PEKING UNION MEDICAL COLLEGE 

minutes was effective for preventing the growth of Bacillus pestis, 
in the case of mercuric perchloride only twenty minutes' immersion 
in 0.2 per cent solution, or thirty minutes in o.i per cent and 0.05 
per cent solutions, was reliable; in the case of lysol (many brands 
used) twenty minutes' immersion in 1 per cent solution was nec- 
essary. Alcohol, either 90 per cent or undiluted, easily sterilized the 
sputum in three minutes; when diluted it was of no use. Both slaked- 
lime and lime-water were effective in thirty minutes. The other 
chemicals, including some much advertised specimens, appeared 

ineffective. 

The viscosity of the sputum should, however, be taken into ac- 
count when drawing any conclusion, but it may be wise for sanitary 
departments to consider these findings before launching into large 
purchases of so-called disinfectants for the control of plague 
epidemics. 

EXPERIMENTS UPON TARABAGANS 

Having failed to observe the existence of plague among marmots 
in the natural state, our next step was to ascertain how far such 
animals were susceptible to the Bacillus pestis under laboratory 
conditions. Like all rodents, the marmot, when inoculated subcu- 
taneously or intraperitoneally with Bacillus pestis, developed septi- 
cemic plague, as has been shown by Strong, Kitasato, and myself. 
But I was anxious to observe the results of inhalation of the plague 
bacillus upon the animal. Dr. Strong conducted one such experi- 
ment at Mukden in 191 1 upon two large tarabagans, and although 
both died, only one showed undoubted signs of primary lung infec- 
tion. In 1 91 6 Eberson and I continued these inhalation experiments 
upon the small marmot {Spermopbilus citillus) found in large num- 
bers around the graveyards of Mukden. A number of these animals 
received inhalation of Bacillus pestis ejected from a fine spray and 
were then thrown among others serving as contacts. The results 
were as follows (6) : 

First Series 

Marmots inoculated 12 Deaths 8 

Contacts 10 Deaths 3 

Total 22 Total 11 



MORNING ADDRESSES 201 

Second Series 

Marmots inoculated 7 Deaths c 

Contacts 9 Deaths 7 



Total 16 Total. 



12 



We could, therefore, reproduce conditions among small marmots 
similar to those observed among men, although the percentage of 
deaths among the animals (68.4 per cent of those who received in- 
halation and 52.6 per cent of contacts) might be higher than among 
human beings during epidemics. 

In August, 1 92 1, we commenced a series of experiments in Harbin 
upon the Mongolian marmot or tarabagan {Arctomys bobac) with a 
view to finding not only the susceptibility of this animal to plague 
pneumonia but also the existence, if any, of chronic or subacute 
plague among the species. 

Experiment B. Tarabagan 1 was firmly strapped upon the pre- 
pared stage with the nose held inside an iron muzzle. It was then 
covered with an oblong metal box open at the bottom and having a 
small circular aperture at the top for the introduction of the nozzle 
of a spray. 

A forty-eight hour agar slant culture of a virulent strain of Ba- 
cillus pestis from the 1921 epidemic was suspended in 10 cc. of salt 
solution and sprayed from a graduated cylinder fitted with a very 
fine nozzle. The technique is the same as in the Mukden experiments 
(6). 

The same experiment was repeated upon Tarabagans 4, 7, and 
10. Each animal so inoculated was kept with two healthy ones in a 
cage measuring 2 by 2 by 2 feet. Two cages had flea proof iron gauze 
partitions to prevent the possibility of flea complication. The 
operators took all antiplague precautions. 

Experiment C. When Tarabagans 1, 4, and 10 died, eight healthy 
animals were introduced among the contacts, two into each cage, so 
that for the two experiments twenty animals were employed alto- 
gether. Rabbit controls were used in every case (Rabbits 1, 4, 7, and 
10). 

Experiment D. The same experiment as Experiment B was re- 
peated with six tarabagans (Tarabagans 31 to 36), the first two 



202 PEKING UNION MEDICAL COLLEGE 

animals receiving direct inhalation from cultures obtained from 
dead Tarabagans i and 10 and the other four serving as contacts. 
All were placed in one cage i\ by 2 by 2 feet with no wire partition. 
Results. All the six control rabbits died. 

Rabbit i died in 36 hours. 

Rabbit 4 " " 40 

Rabbit 7 " " 50 

Rabbit 10 " " 50 

Rabbit 31 " "130 " (51 days). 

Rabbit 32 " "154 " (6* " ). 

Of the marmots, Tarabagan 4 died in four and one-half days, 
showing at postmortem much inflammation of epiglottis and trachea, 
marked hemorrhages in left lung, peritoneum, and intestines. 
Tarabagan 10 died in five and one-half days showing at postmortem 
blood-stained froth from nose and mouth (as in man), congestion of 
trachea and bronchi, with a quantity of pink sputum and distinct 
hemorrhagic spots not unlike pneumonia in the lungs. Tarabagan 1 
died seven and one-half days after inhalation and showed dark 
swollen cervical and bronchial glands, hyperemic trachea, and 
bronchi with pink sputum, and red patches of pneumonia in both 
lungs. Tarabagan 7 remained alive until the seventeenth day when 
it was killed with chloroform after a struggle of twenty minutes. At 
postmortem it showed swollen, dark cervical glands, slightly con- 
gested trachea, with semipurulent contents, many yellow patches in 
lung substance which on section proved to be abcesses. In the spleen, 
too, an abcess was observed at the anterior horn. The first three 
animals evidently died of plague pneumonia, while the fourth devel- 
oped a subacute form of plague which did not seem to inconvenience 
it. Numerous plague bacilli were found in all animals except Tara- 
bagan 7, where only a (ew scattered bacilli were seen in the heart's 
blood, peripheral blood, lung tissue, and cervical glands. 

One contact which had been with Tarabagan 10 was also killed 
on the seventeenth day and showed no apparent lesions in the or- 
gans, but some plague bacilli detected in the heart's blood were con- 
firmed by cultures later on. 

Both of the animals that received direct inhalation in Experiment 
D died (Tarabagan 31 in five and one-half days and Tarabagan 32 



MORNING ADDRESSES 203 

in six and one-half days) and showed at necropsy changes similar to 
the others receiving inhalation in the other experiments. 

The occurrence of plague bacilli, although few. in numbers, in the 
blood of the two living tarabagans is of supreme importance, be- 
cause it may explain the secret of the strange infections which have 
taken place in Siberia among Russians developing plague after 
skinning and eating apparently healthy animals. There are now 
under observation at Harbin still nineteen tarabagans which have 
been in contact with lung infected animals and their progress will 
be watched with interest. 



POSTMORTEM RECORDS 



Besides those at Hailar and Dalainor, we conducted forty-three 
complete postmortem examinations at Harbin, thirty-four of which 
were upon plague subjects, during the period from February 27 to 
May 21. Our findings will be related in detail before the Conference 
of Japanese Physicians at Port Arthur on September 24, but it may 
be interesting to note here that in the first part of the epidemic 
(before April 27) all cases except three babies were pneumonic. On 
that date one septicemic case was recorded, while during the two 
ensuing weeks all three necropsies done showed primary lung lesions. 
After May 13 every one of the ten postmortems performed was 
septicemic except one man who had a small patch of bronchopneu- 
monia. From these pathological cases and our former clinical obser- 
vations, it appears to us that the preponderance of the septicemic 
cases in the latter course of the epidemic exercised a marked influence 
upon its termination. If so, how was it effected? Could it be that the 
organisms passing through pneumonic cases were becoming so 
virulent that there was little or no time for the patients to develop 
pulmonary symptoms, and the medium of infection, namely the 
sputum, was therefore absent. As a consequence the later victims 
became less infectious, though invaded by more virulent bacilli, 
fewer infections took place, and the epidemic gradually died out. 
The alternative, namely, a diminished virulence of the organism on 
account of the warmer weather has little scientific evidence to sup- 
port it; in our experiments conducted this summer the original 
strains grown in the winter seem to be as virulent as ever. 



2o 4 PEKING UNION MEDICAL COLLEGE 

TREATMENT AND PROTECTIVE INOCULATION 

The treatment of pneumonic plague, in this as in previous epi- 
demics, proved exceedingly unsatisfactory and no authentic case is 
on record where any serum or medicine has saved life. In our hos- 
pitals, antiplague serum, neosalvarsan, eusol, formalin, sodium 
gynocardate, and methylene blue were tried but they were of no 
avail. No remedy has so far been found sufficiently powerful to stop 
the rapid distribution of the bacilli through the lungs and the blood. 

While engaged upon the experiments dealing with the action of 
disinfectants upon sputum, we noticed on frequent occasions that 
when the cultures were contaminated with a spore-bearing bacillus 
plague organisms did not grow. This accident put into our heads the 
possibility of using the spore-bearing organism for protective inocu- 
lation. So this organism was isolated and found to be non-pathogenic 
and similar to the potato bacillus. The guinea pigs were next inocu- 
lated with emulsions of the pure cultures. In the stress of the mo- 
ment, whole agar slants of virulent plague bacilli were then injected 
into the peritoneum of each of these guinea pigs. The first guinea 
pig died in two and one-half days, the second in five days, and the 
third in six days, whereas under ordinary circumstances such large 
doses would prove lethal in eighteen to twenty-four hours. Necropsy 
revealed in every case a localized peritoneal abscess with matting of 
the liver, spleen, omentum, and intestines, as if a strong local reac- 
tion had taken place. Under the microscope the pus showed besides 
the spore-bearing bacilli numerous plague bacilli, but the heart's 
blood showed only a few or none at all. Encouraged by these results, 
an emulsion of agar cultures of this spore-bearing bacillus, as well as 
a subtilis-like organism grown in large flasks, was injected into two 
plague patients, respectively, with however no apparent relief. The 
conditions, however, under which we were at that time working were 
not favorable, as our men were continuously threatened by the 
ignorant populace with personal violence and our hospital with 
fire. A well-fitted, glass-lined ward with a separate compartment 
where the operator could give intravenous injections might have 
been more satisfactory than the close, sparsely heated rooms where 
hundreds of patients had previously died. 



MORNING ADDRESSES 205 

While the above experiments are far from complete, we shall 
continue them with a view to discovering a virus, which while deadly 
to the parasite is harmless to the host, a process which has already 
been successfully used by the employment of rat-typhoid virus in 
combating plant parasites and in the extermination of plague-bear- 
ing rodents. 

As is generally known to bacteriologists, the Bacillus pestis re- 
sembles morphologically the bacteria of a group classed under "hem- 
orrhagic septicemia," whose other members produce highly fatal 
infectious diseases among lower animals. To this class of disorders 
belong especially the affections known as swine plague, fowl cholera, 
rabbit septicemia, and rinderpest. The bacilli are short, non-motile, 
non-spore-forming, Gram-negative with a tendency to bipolar stain- 
ing. While the organisms of fowl cholera and swine plague are ex- 
tremely fatal to their respective hosts, they are apparently quite 
harmless to man. Vice versa, the Bacillus pestis, so virulent to man, 
is absolutely innocuous to chickens, ducks, and pigs, as we have 
again proved by injecting even 5 cc. of human plague blood into a 
series of these animals, with negative results. Is it possible that our 
future hope of protection against pneumonic plague lies in these 
organisms of the same family? Or, shall we look to Koch's tubercle 
bacillus and allied bacilli for the solution? 

May I make an appeal before closing this address? Through the 
generosity of Mr. Rockefeller, we have been enabled to witness the 
inauguration of this unrivalled home of medical training. The Rocke- 
feller Foundation, by its marvellous organization, splendid resources, 
and true spirit, has conferred untold benefits upon a large part of the 
world. It has established this unique hospital and medical school in 
our midst. There are keen men of science in this as in other coun- 
tries, who need only encouragement and opportunity to accomplish 
great deeds. At present, owing to incessant political strife and the 
general ignorance of modern science brought about by a non-pro- 
gressive education based largely upon old classics, those undertaking 
research are seldom understood or appreciated. Is it too much to ex- 
pect the Rockefeller Foundation to extend its beneficent activities 
and found in the insanitary yet glorious old land of China another 



206 PEKING UNION MEDICAL COLLEGE 

Rockefeller Institute, similar to but perhaps smaller in size than that 
in New York, where the historic work of Welch, Flexner, Noguchi, 
Heiser, and Carrel may be duplicated in such diseases as leprosy, 
beri-beri, malaria, tuberculosis, intestinal parasitism, plague, sprue, 
trachoma, malignant scarlatina, and other affections peculiar to the 
East? As one who has been fighting for the right to work during the 
last fourteen years, I earnestly hope that the Trustees of this, the 
greatest individual charitable organization in the world's history, 
may seriously consider it. 

SUMMARY 

i. Pneumonic plague epidemics arise as a secondary manifesta- 
tion of bubonic plague. 

2. The prevalence of purely septicemic cases towards the end of 
the epidemic is significant as a probable explanation of its decline 
and termination. 

3. Subacute or chronic plague may exist among the tarabagans in 
Mongolia and Siberia, giving rise to periodic outbreaks of bubonic 
plague in man, as a result of direct infection from injury due to 
skinning by trappers or marmot eaters. 

4. The tarabagan is easily susceptible to pneumonic plague pro- 
duced by inhalation of the Bacillus pestis in spray form. 

5. The existence of pneumonic plague carriers was proved in the 
1 92 1 Manchurian epidemic. 

6. Rooms where patients have died of pneumonic plague are not 
particularly dangerous. In all four instances recorded, sick patients 
travelling in railway cars have not infected their fellow passengers. 

7. Disinfectants and antiseptics even in strengths above those 
usually employed have very little effect upon plague sputum. The 
use of alcohol is the surest means of sterilizing the hands and gloves 
in plague work. 

8. We have cultivated plague bacilli from the seemingly dry 
sputum of patients. 

9. The mask is the principal means of personal protection against 
pneumonic plague. 

10. The problem of successful vaccination against pneumonic 
plague still awaits solution. 



MORNING ADDRESSES 207 

BIBLIOGRAPHY 

i. McCoy, G. W., Am. J. Hyg., 1921, i, 182. 

1. First Annual Report, Ministry of Health, London, 1919-20, 38. 

3. Medical News, Lancet, 1919, ii, 810. 

4. Wu Lien Teh, J. Hyg., 1913, xiii, 237. 

5. Barber, M. A., and Teague, O., Philippine J. Sc, 191 2, vii, B, 255. 

6. Eberson, F., and Wu Lien Teh, J. Infect. Dis., 1917, xx, 170. 



THE CLINICAL IMPORTANCE OF THE VITAL CAPACITY 

OF THE LUNGS 

By 

Francis W. Peabody, M.D. 

INTRODUCTION 

In T'he Doctor s Dilemma Bernard Shaw makes old Sir Patrick 
Cullen tell his young colleague, flushed with pride at a new discov- 
ery, that "most discoveries are made regularly every fifteen years." 
This cynical questioning of all progress in medicine is unwelcome to 
us, but there is much truth in the fact that the younger generations, 
walking by different lights and along apparently new paths, find 
themselves facing the very problems that confronted their fathers 
and very little better equipped to solve them. The vital capacity of 
the lungs, or the volume of the deepest expiration after the greatest 
possible inspiration, was the subject of a brilliant and painstaking 
investigation seventy-five years ago, in which its physiological signifi- 
cance was discussed and its bearing on clinical medicine indicated. 
After receiving a considerable amount of attention, chiefly on ac- 
count of its practical interest, the subject faded into the background 
and was lost sight of by clinicians, but within the last few years it 
has again begun to assume an importance in medicine. 

EARLY WORK 

In 1846, John Hutchinson (1) published his paper, "On the 
Capacity of the Lungs and on the Respiratory Functions, with a 
View of Establishing a Precise and Easy Method of Detecting 
Disease by the Spirometer." Like so many of the articles by the 
older school of English physicians it has achieved the position of a 
classic and all that has been since added to the subject is develop- 
ment of detail, almost in the nature of ornamentation. Hutchinson 
was not the first to attempt to determine the vital capacity of the 
lungs for in his careful survey of the literature he mentions a number 
of earlier investigators, but all of them used crude methods and 
made few observations, whereas, as Hutchinson says, this is the 

208 



MORNING ADDRESSES 209 

type of investigation which "demands for its solution a multitude 
of experiments, almost without limitation." The care which he took 
to fulfill its critical requirements is illustrated by the fact that he 
examined 2,130 persons of different types, including sailors, paupers, 
Royal Horse Guards, Woolwich Marines, draymen, girls, and even 
gentlemen. Hutchinson was the first to realize that the magnitude 
of the capacity of the lungs depends on other bodily functions and 
to attempt to determine with what function it was most closely 
related. He also appreciated fully the effect of disease on the vital 
capacity and gave striking illustrations of the value of determina- 
tions of the vital capacity of the lungs in diagnosis and prognosis of 
pulmonary tuberculosis. And finally, it was Hutchinson who made 
the method available for general use by devising a simple and accu- 
rate spirometer, the form of which has not been substantially altered. 
John Hutchinson saw from the outset that the importance of 
spirometry as an aid to the clinician depends largely upon the 
possibility of establishing reliable normal standards, deviation from 
which would indicate a pathological condition. For this reason, in 
sad contrast to much present-day so-called scientific work, he 
devoted by far the greater part of his attention to the study of what 
we should call the "normal control." His conclusions were that the 
three factors having the most marked effect on the vital capacity of 
the lungs are weight, height, and age. Height was found to have the 
greatest influence and he says that "for every inch of height (from 
5 feet to 6 feet) 8 additional cubic inches of air, at 6o°, are given out 
by a forced expiration." The effect of weight was found to be more 
irregular than that of height, and, unless there is abnormal obesity, 
it is overwhelmed by that of height. Age appeared to have less in- 
fluence than height or weight but Hutchinson states that the vital 
capacity increases from fifteen to thirty-five years and decreases 
from thirty-five to sixty-five years. The circumference of the chest, 
the length of the trunk, and the size of the chest as determined by 
plaster casts were studied and seemed to have little effect, but 
slight changes in the vital capacity due to posture were described. 
Many investigators since the time of Hutchinson have applied 
themselves to the attempt to find more reliable normal standards. 
Wintrich (2) (1854) made determinations on 3,500 normals and 

15 



210 PEKING UNION MEDICAL COLLEGE 

states that height, age, and sex are the chief factors of importance. 
The influence of old age is shown mainly after 50 for the figures be- 
tween forty and fifty differ little from the minimum values for 
the age period of twenty to forty. He mentions as other factors, 
(1) the effect of eating and drinking in raising the diaphragm, (2) 
constipation, and especially (3) a rapid respiratory rate, which may 
prevent the taking of a deep breath, but he found that pregnancy ex- 
erts little influence on the vital capacity. Arnold (3) (1855) made a 
similar extensive study and attempted to estimate the effect of age, 
sex, size, expansion of chest, and habits of life on the vital capacity. 
Waldenburg (4) (1875) agreed essentially with Arnold but found the 
quantitative effect of height to be slightly different. He also cites 
Muller (1868) who described a lung capacity quotient which varies 
directly with the square of the chest circumference and the length of 
the trunk and he believes this to be the best basis for comparison. 
Waldenburg, as well as other earlier authors, lays special stress on 
the fact that under given circumstances the vital capacity of any 
individual remains extremely constant. In 1918, Lundsgaard and 
Van Slyke (5) correlated the vital capacity of the lungs with the 
chest volume as calculated from three easily obtainable measure- 
ments of the thorax, but the number of individuals studied was only 
eighteen, and in a larger series West (6) subsequently found that 
the method offered no advantages. 

RECENT INVESTIGATIONS 

The factors already mentioned remained the chief ones with 
which it was attempted to correlate the vital capacity of the lungs 
until quite recently when it became apparent that certain physio- 
logical functions, such as the basal metabolism, bear a very close 
relationship to the area of the body surface. In 1917, Peabody and 
Wentworth (7) suggested that vital capacity might vary more 
closely with surface area than with the factors hitherto employed 
and a small number of observations seemed to bear this out. In 1919, 
Professor Dreyer (8) of Oxford published very complete observa- 
tions on nineteen normal persons and concluded that the relation 
between surface area and vital capacity is constant, but that the 
value of K will vary for groups of individuals whose nature of life 



MORNING ADDRESSES 



211 



and habits are distinctly different. Finally, in 1920, West (6) stud- 
ied 129 normals at the Peter Bent Brigham Hospital (eighty-five 
men and forty-four women) and again showed that the vital capac- 
ity varies more uniformly with surface area than with any other 
function. West found for men an approximate standard value of 
2.5 liters vital capacity per square meter of body surface and for 
women a value of 2.0 liters per square meter. The area of body sur- 
face is readily determined from the height and weight by means of 
the chart of Du Bois and Du Bois (9) so that in West's calculations 
the three great determining factors of height, weight, and sex are 
accounted for. It is interesting and satisfactory that the calculation 
of West's figures by means of the formula of Dreyer showed prac- 
tically complete agreement, so that it is unimportant whether one 
expresses results in percentage of normal, according to West, or as a 
variation of a constant, according to Dreyer. Of West's subjects 71 
per cent had a vital capacity within 10 per cent of the normal 
standards and only $.5 per cent had a vital capacity more than 10 
per cent below the normal standard. As will subsequently be seen, 
it is the decrease below normal standards that is of significance in 
pathological conditions. 

At the present time there is no doubt that the most reliable 
standards on which to base abnormal deviations of the vital capac- 
ity of the lungs in disease are those of Dreyer (8) and West (6), 
which take into consideration sex and body surface area. Our 
knowledge of this fundamental aspect of the subject is, nevertheless, 
still very incomplete. Much remains to be learned about the varia- 
tions of these standards with age for the results of both Dreyer and 
West deal almost exclusively with young adults. Infinitely more 
baffling are the effects on the vital capacity of different habits of 
life. Physical exercise and athletic training tend to increase the 
vital capacity, while a sedentary existence exerts its influence in the 
opposite direction, but the effects do not appear to be constant and 
it is doubtful whether they can ever be satisfactorily expressed 
quantitatively. As in many other bodily functions, such as pulse 
rate, respiration rate, and even temperature, one must accept the 
fact that there will always be certain individual variations from 
general standards of normality. It is important to appreciate, how- 



212 PEKING UNION MEDICAL COLLEGE 

ever, that this does not detract essentially from the value of such 
normal standards. It merely indicates that individual findings 
should be interpreted with judgment and in the light of broad ex- 
perience, in exactly the same way that it is necessary to interpret 
many other findings in clinical medicine, and it illustrates the gen- 
eral importance of a knowledge of this as of other functions in any 
individual while in a normal state. 

VALUE OF SPIROMETRY 

Before referring to the alterations in the vital capacity of the 
lungs which occur in different specific diseases, it will be well to 
consider the fundamental physiological significance of such altera- 
tions, and to make clear the general type of information that may 
be obtained by means of spirometry. A decrease in the vital capac- 
ity occurs in many clinical conditions, but it is not of direct or 
specific diagnostic moment. The determination of the vital capacity 
is to be regarded purely as an index of the functional capacity of 
one part of the respiratory mechanism and particularly as a means 
of obtaining information as to a diminution of its normal reserve 
power. Just as the phenolsulphonethalein test gives information re- 
garding some, but not all, of the functions of the kidney, so the de- 
termination of the vital capacity gives an insight into one function 
of the lungs. The physiological activities of the external respiration 
may be broadly grouped into two categories; those which are re- 
lated to the pulmonary movements, the expansion and collapse of 
the lungs, and those which have to do with the respiratory mem- 
brane. As a respiratory membrane, the function of the lungs is es- 
sentially to promote the interchange of gases between the blood and 
the air in the alveoli, and this has only an indirect relationship to 
the vital capacity. The movement of the lungs, on the other hand, 
by which the ventilation of the alveoli is brought about, is very 
directly dependent on the vital capacity because it is this factor 
that largely determines the extent of the expansibility of the lungs 
and thus the possible extent of the pulmonary ventilation. The 
practical importance of the adaptability of pulmonary movements 
to bodily needs is self-evident, for an increase in pulmonary ventila- 
tion almost necessarily accompanies any increase in metabolism 



MORNING ADDRESSES 213 

whether this be due to exercise, to fever, or to some other stimulant 
such as that associated with hyperthyroidism. When a man lies 
quietly at rest his bodily activities are nearly at a minimum and his 
total metabolism is approximately what we regard as "basal." In 
this state his oxygen requirements are small and the necessary 
amount of oxygen is easily supplied to the arterial blood by slow 
and rather shallow breathing. The minute-volume of pulmonary 
ventilation is low. With any increase in muscular activity the 
organism will require more oxygen and the absorption of this addi- 
tional oxygen, as well, of course, as the elimination of increased 
amounts of carbon dioxide formed, is accompanied by an augmenta- 
tion of the minute-volume of air which is brought into contact with 
the blood in the capillaries of the lungs. The minute-volume of air 
breathed increases with the metabolism but in general at a slightly 
less rapid rate than the latter. This rise in minute-volume is brought 
about by increasing both the rate and depth of breathing. Practi- 
cally, however, on account of the fact that with each respiration a 
certain proportion of the inspired air remains in the upper respir- 
atory tract or "dead space" and thus takes no part in gaseous 
exchange, it is much more economical to take deep and slow respira- 
tions than to take shallow and rapid respirations. With deep breath- 
ing the ventilation of the alveoli of the lungs, where gaseous inter- 
change takes place, is brought about with a lower total ventilation 
than with shallow breathing. The highest minute-volume that any 
individual is capable of maintaining in response to the requirements 
of his metabolism will depend on his ability to increase the rate and 
depth of breathing and on the balance between rate and depth. 
Practically, a healthy young man who is carrying on extremely 
hard exercise breathes about ten times as large a volume of air as he 
does when at complete rest. This difference between the minute- 
volume of air breathed at rest and the highest minute-volume that 
can be maintained represents what may be called the "pulmonary 
reserve" — the reserve power of the external respiratory mecha- 
nism to be called upon in time of need. The pulmonary reserve de- 
pends on rate and depth of breathing, but of these two factors the 
ability to increase rate is at the same time the least important and 
the least affected by pathological conditions. The rate at which the 



2i 4 PEKING UNION MEDICAL COLLEGE 

respiration can be carried on effectively and continuously is some- 
what definitely limited and even with hard exercise it is unusual to 
find rates much above 35 per minute. The more important factor, 
therefore, in increasing the minute-volume of air breathed is the 
depth of breathing, and, as a corollary to this, it is evident that the 
limits to which the minute- volume can be increased and to which the 
pulmonary mechanism can be adjusted to the needs of the body will 
depend very largely upon the ability to increase the depth of the 
respiration. It is here that the vital capacity becomes the prominent 
determining factor, for the ability to breathe deeply depends very 
largely on the vital capacity of the lungs. It is obviously impossible 
to use the total volume of the vital capacity for continuous respira- 
tion and even under the most favorable circumstances only a com- 
paratively small proportion is available. In a series of normal young 
men who rode a stationary bicycle until they were forced to stop on 
account of dyspnea, it was found that at the end, when the minute- 
volume was greatest, they were using on the average about one- 
third of their vital capacity at each respiration. Roughly, therefore, 
one may say that a normal man with a vital capacity of 4,500 cc. 
will breathe 400 cc. per respiration while he is quietly at rest and 
that with his maximum requirement it is possible for him to breathe 
about four times as much, or 1,600 cc. per respiration. 

If, however, owing to some pathological condition, his vital capac- 
ity is reduced 50 per cent to 2,000 cc, the same subject will be able 
to increase the depth of his respiration only from 400 cc. at rest to 
700 cc. when he is exercising. With a rate of respiration of 3$ per 
minute he would be able to keep up a minute-volume of 56 liters in 
the first instance but of only 25 liters in the second. ^Yhereas in his 
normal state he could theoretically carry on his metabolism at about 
ten times its normal level so that he could run a race, his condition 
when his vital capacity was reduced would be such that he could 
meet only a fivefold increase in metabolism and would become short 
of breath walking rapidly upstairs. The decrease in vital capacity 
may thus give a fairly accurate indication of the amount of physical 
activity which can be undertaken without the production of dyspnea. 
The determination of the vital capacity will instruct us as to the 
functional capacity of the external respiration for it will serve as an 
index of the respiratory reserve. 



MORNING ADDRESSES 215 

EFFECT OF DECREASE IN VITAL CAPACITY 

An actual experiment, illustrated on the accompanying table, indi- 
cates the effect of a decrease in the vital capacity of the lungs on the 
respiratory mechanism and the production of dyspnea. The subject 
was a normal medical student and the reduction of the vital capac- 
ity was produced by the use of a tight chest swathe which restricted 
the movements of the thorax. 

In spite of the artificiality of the procedure it will serve a purpose 
for it demonstrates the simple mechanical effect of a decrease in 
vital capacity on the production of dyspnea, and is not complicated 
by the numerous other factors which are present in most pathologi- 
cal conditions. On the whole, it gives a fairly accurate representation 
of the picture in a pleural effusion in which dyspnea rests largely on 
a mechanical basis. In Experiment A, the subject has a normal vital 
capacity of 4,200 cc. If, as has been stated, a normal person carrying 
on extremely hard exercise breathes at a rate of about 25 per minute, 
and uses approximately one-third of his vital capacity at each res- 
piration, then one may calculate the maximum minute-volume 

/V.C. . ^ 

possible for this subject as 49 liters ( — '- — : X35 = 49 liters J . In Period 

1, at complete rest, his minute-volume is 4.2 liters, or only 9 per 
cent of his possible maximum. In Period 2, he walked upstairs on a 
treadmill at a constant rate for one minute and the minute-volume 
rose to 12.9 liters. In this, as in all other similar observations, it has 
been found that the dyspnea noticed by the subject is greater in the 
first minute after walking than during the exercise itself. In Period 
3, after the walk, the minute-volume has risen to 15.0 liters, or 31 
per cent of the maximum minute-volume. With this minute- volume 
the subject was conscious of breathing somewhat deeply but was 
not at all short of breath. In Period 4, he repeated exactly the walk 
in Period 2 but carried a pack weighing 50 pounds on his back. The 
minute- volume rose to 17.8 liters, and in the first minute after 
(Period 5) it was 23.8 liters, or 49 per cent of his maximum minute- 
volume. During this period (Period 5) the subject was slightly 
dyspneic. The increase in minute-volume is obtained by increasing 
the rate of respiration to 20, and increasing the volume per respira- 
tion from 320 to 1,190 cc. In Period 5, the volume of each respiration 



21 6 



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MORNING ADDRESSES 217 

is 28 per cent of the vital capacity of the lungs, but the rate of 
respiration is comparatively slow and the subject has little difficulty 
in maintaining the necessary minute-volume. In Experiment B, the 
same observations were made on the subject after his vital capacity 
had been reduced to 2,800 cc. by a chest swathe. At this time the 
theoretical approximate maximum minute-volume is only 33.0 liters 
because of the decrease in vital capacity. In Period 3, after the first 
walk, the minute- volume was 21.4 liters, or 65 per cent of the maxi- 
mum minute- volume, and the subject noted much more dyspnea 
than during Period 5 in Experiment A. In Period 5 (Experiment B), 
the minute-volume was 24.9 liters, or 75 per cent of the maximum, 
and the dyspnea was great. It will be seen that in this experiment, 
as in Experiment A, the subject increases the depth of respiration 
until it is about 28 per cent of his vital capacity, but this is so low in 
Experiment B (778 cc.) that it becomes necessary to increase the 
rate in order to maintain the minute-volume necessary to supply the 
oxygen required by the high metabolism. In Period 5 the rate 
reaches nearly the highest that one expects to find during severe 
exercise. By comparing the figures which indicate the percentage of 
the maximum minute-volume which is being used it will be seen 
that as this percentage rises the feeling of dyspnea increases pro- 
gressively so that with 50 per cent the dyspnea is slight, but with 75 
per cent it is very marked. The amount of work done in Period 4 was 
the same in both experiments, but in Experiment B much more 
dyspnea was produced than in Experiment A. In Experiment B the 
vital capacity was low and the subject could not breathe as deeply 
as in Experiment A, so it became necessary for him to increase the 
rate of respiration. The values for minute-volumes are higher for the 
corresponding periods in Experiment B than in Experiment A and 
this is due to increased rate and relative increase in "dead-space," 
but for the sake of simplicity these points will not be discussed. The 
important point to be observed from the experiments is that the 
inability to increase the depth of respiration is the factor which 
reduces the pulmonary reserve in Experiment B and causes the 
production of dyspnea. This inability to breathe deeply, depends on 
the vital capacity of the lungs, and thus the vital capacity is an 
important factor in determining the occurrence of dyspnea. Indeed, 



2i 8 PEKING UNION MEDICAL COLLEGE 

if one knows the degree to which the vital capacity is decreased it is 
possible to calculate with a fair degree of accuracy the maximum 
minute-volume which a patient can maintain and thus foretell how 
much physical exercise he is capable of without undue shortness of 
breath. 

What has been said so far should not, of course, be taken to sug- 
gest that changes in the vital capacity of the lungs are the only fac- 
tors in the production of dyspnea. This is obviously far from being 
the case. Even among normal individuals with vital capacities of 
equal size there is a wide variation in the tendency to dyspnea. 
Physical training and the development of skeletal muscle determine 
the ability to keep up continuously a high pulmonary ventilation 
without fatigue, while the character of the heart muscle, the rate of 
circulation, the morphological and chemical constitution of the 
blood, and the state of the respiratory membrane are merely a few 
of the other factors which may affect the delivery of oxygen to the 
tissues and the removal of carbon dioxide, and thus play a role in 
the production of dyspnea. Nevertheless, in certain pathological 
conditions dyspnea is due very largely to an inability to increase the 
ventilation of the lungs, and it is important, as well as interesting, 
to the clinician that this decrease in the reserve power of a vital 
function can be followed in a quantitative way by means of spi- 
rometry. 

VITAL CAPACITY IN RELATION TO DISEASE 

Having discussed in some detail the general significance of the 
vital capacity of the lungs, we may now turn to a consideration of 
the subject in its relation to disease. There are many conditions 
which may cause a decrease in the vital capacity. Anything which 
interferes with the respiratory movements of the thorax may do it; 
for example, extreme general muscular weakness (as after prolonged 
infections), calcification of costal cartilages, arthritis and similar 
conditions affecting the mobility of the ribs, as well as intra-abdom- 
inal conditions which inhibit the descent of the diaphragm. Pleural 
effusion or pleural pain may act in the same way. Inflammatory and 
infiltrative lesions affecting the lung substance, such as pneumonia, 
tuberculosis, and carcinoma, decrease the vital capacity by oblitera- 
tion of air spaces as well as by interference with lung mobility. In 



MORNING ADDRESSES 219 

emphysema an alteration of the elasticity of the lung, associated 
with inability to collapse, decreases the vital capacity. In heart 
disease still another element enters in and the lowering of the vital 
capacity depends on increased pressure in the pulmonary circula- 
tion and engorgement of the pulmonary vessels. Finally, of course, 
in any given case several of these factors may be operative at the 
same time, so that in a severely decompensated cardiac patient the 
low vital capacity may be due to circulatory disturbances, pleural 
effusion, pulmonary infarct, and a superimposed bronchitis. 

If, therefore, the situation is so complex, and such a variety of 
causes may bring about changes in the vital capacity of the lungs, 
one may well ask what it is that spirometry has to offer to the clini- 
cian. It is quite evident that it offers nothing of a specific diagnostic 
nature. Like many other clinical methods, such as the determination 
of the temperature, the leucocyte count, the presence of albumin in 
the urine, or the gastric acidity, it merely indicates a general type 
of process and leaves it to the observer to discover the underlying 
cause and to interpret its significance. But the determination of the 
vital capacity goes a little further, for it gives, within certain limits, 
an idea of the extent of the process. It has a quantitative value. It 
shows that the function of pulmonary ventilation is affected, and it 
indicates the degree of the pathological condition. It supplements 
the history, physical examination, and X-ray examinations by giv- 
ing additional information as to the functional capacity of the lungs. 
It may also indirectly indicate the extent of anatomical involve- 
ment of the lungs; for in many cases of tuberculosis or cancer, for 
instance, the vital capacity test indicates an involvement much 
greater than is suggested by the physical signs and one that is more 
in harmony with the X-ray and autopsy findings. Sometimes, in- 
deed, as in two cases of metastatic carcinoma of the lung recently 
observed, the changes in vital capacity appear to follow the progress 
of the disease even more accurately than the X-ray pictures. As a 
functional test, it gives an indication of the pulmonary reserve, and 
in heart disease enables one to tell, while the patient is still in bed, 
just about how much physical activity he is capable of without 
developing dyspnea. The determination of the vital capacity at 
intervals of time gives much information as to the course of the 



220 PEKING UNION MEDICAL COLLEGE 

disease, and, as it is a quantitative method, it can be used for 
graphic expression. Spirometry may also serve as a valuable check 
on the history, especially as regards the history of dyspnea, which 
may be either understated or exaggerated. Thus, a patient with 
heart disease who says he has no dyspnea on exertion may be found 
to have a low vital capacity, and it is discovered that the absence of 
this symptom is due to the very limited life he leads. Or a patient 
who complains of great dyspnea on exertion is found to have a nor- 
mal vital capacity and the suggestion is clear that the symptom is 
due, not to organic disease, but to some nervous factor in his condi- 
tion. This point has often been of assistance in differentiating cases 
of so-called "effort syndrome" in which the physical examination 
suggested the possibility that the dyspnea might be due to early 
cardiac disease. 

There are certain definite limitations to the clinical use of spirom- 
etry. The most important of these is the unwillingness or inability 
of certain persons to co-operate to the full extent of their ability. 
The test is not wholly objective and it is worthless unless the subject 
co-operates completely. This difficulty is met with in patients who 
do not understand what is desired, in very sick patients, and in cer- 
tain highly neurotic individuals. The second important limitation to 
the value of spirometry is the comparatively wide normal variation 
from the average standards. This may be in some degree obviated 
by the development of better standards but at present the changes 
from time to time in any individual case are of more value than are 
the relative deviations from the normal standards. For practical 
purposes it may be assumed that normal young adults have a vital 
capacity of at least 90 per cent of the normal standards, but it must 
be remembered that this is a general figure and a few normals will 
fall a little lower. Still greater deviation must be allowed for subjects 
over fifty years of age until satisfactory standards have been estab- 
lished for the decades from fifty to seventy years. The question of 
the effect of general weakness must also be considered when determi- 
nations are made on persons who have been sick for a long time. 
The fact, however, that patients with pernicious anemia, a disease 
with a prolonged course in which general weakness is a prominent 
feature, usually have a vital capacity of more than 80 per cent of the 



MORNING ADDRESSES 221 

normal shows that, except in extreme cases, general weakness is not 
important (Peabody and Sturgis (10)). Fatigue or weakness of the 
muscles of respiration appears to be a less important factor than 
might be expected. This is indicated also by observations on a group 
of patients with heart disease in whom the vital capacity was low. 
An attempt was made to tire out the muscles of respiration by tak- 
ing the vital capacity every fifteen seconds for ten minutes, but 
at the end of the forty observations the vital capacity was just as 
high as at the beginning. 

SPIROMETRY AS A TEST OF PHYSICAL FITNESS 

Practical interest in spirometry has recently been shown in two 
directions. It has been investigated in its relation to disease, and as 
a test of general physical fitness. The need for the tests of physical 
fitness developed during the war, and Professor Dreyer of Oxford 
suggested the determination of the vital capacity of the lungs as an 
objective method of classifying soldiers according to their physical 
condition. This phase of the subject, however, I shall not touch 
upon. 

Heald and Thomson (11) recognized the value of Dreyer's test 
and combined it with the respiratory tests of Flack in such a way 
that they feel they have developed a much more accurate method 
of discriminating between men who are fit and those who are unfit. 
Observations on a similar group of men were made by Levine and 
Wilson (12), who studied 131 British soldiers with "irritable heart." 
They found that the average vital capacity was slightly decreased 
and corresponded with the general physical condition but that only 
in the group classified as "permanently unfit" was it more than 10 
per cent below the normal standard. This is in agreement with the 
results of Adams and Sturgis (13), who examined 100 American 
soldiers with so-called "irritable heart" and found that only twenty 
had a vital capacity less than 90 per cent of normal. The decrease 
in vital capacity was not sufficient to explain the degree of dyspnea 
complained of. It is interesting that Levine and Wilson found a 
greater fall in vital capacity after exercise in the men who were un- 
fit than in those who were fit. White (14) also made use of the vital 
capacity and the respiratory tests of Flack in estimating the physi- 



222 PEKING UNION MEDICAL COLLEGE 

cal fitness of soldiers. His subjects included normals, convalescents 
from acute infections and from "gassing," "effort syndrome" cases, 
and neurotics with "shell shock." The values for the vital capacity 
and the other respiratory tests were very low in the "shell shock" 
cases. White, therefore, concluded that in the groups under discus- 
sion the vital capacity is a test of nervous stability rather than of 
the condition of the cardiovascular or respiratory systems per se. 
The extraordinary tendency to fatigue in soldiers with "shell shock" 
and in cases of severe "effort syndrome," as well as in the neuras- 
thenics of civil life, is quite definitely due more to weakness of will 
than to weakness of muscle. In all such cases any test involving 
effort or concentration will undoubtedly be of little value except as 
an indication of nervous stability. Where the will is weak the volume 
of air expired will be low, and lower than can be accounted for by 
muscular weakness, but the readings on the spirometer must not be 
taken as indicating any organic disturbance of the respiration. 

VITAL CAPACITY IN RELATION TO PULMONARY TUBERCULOSIS 

Of the diseases in which the vital capacity of the lungs has been 
studied pulmonary tuberculosis has received the most attention. 
Hutchinson (i), in 1846, placed much emphasis on the significance 
of spirometry in the early diagnosis of phthisis and gives an interest- 
ing account of his experience with Freeman, the American prize- 
fighter, then visiting England. At the first observation, in 1842, he 
was found to have a high vital capacity of 434 cu. in., but two years 
later it had fallen to 344 cu. in. At this time he was in ill health, but 
two physicians could find no evidence of pulmonary disease by aus- 
cultation. Freeman subsequently died, however, and at autopsy an 
extensive tuberculosis of the lungs was found. Wintrich, Arnold, and 
others also believed the method to have diagnostic value, and the 
former considered that the vital capacity was of aid in prognosis. 
Low values in phthisis were later reported by many investigators. 
In 1918, Garvin, Lundsgaard, and Van Slyke (15), using normal 
standards based on the chest volume, found a slight decrease in 
incipient cases and a considerable decrease in advanced cases of 
pulmonary tuberculosis. But the development of other improved 
methods for studying tuberculosis relegated spirometry completely 



MORNING ADDRESSES 223 

into the background until in 1920 Dreyer and Burrell (16), at- 
tacking the subject with better normal standards, again advocated 
its use. As a result of their study of a considerable series of cases 
they concluded that it is of value in the classification of patients in 
that this can be done on the basis of a numerical value instead of as 
the result of personal interpretation of physical signs, and that it 
is particularly helpful in following the course of the disease and the 
effects of the treatment. These results have since been confirmed in 
the United States by YVittich, Myers, and Jennings (17), who in- 
vestigated 174 cases of pulmonary tuberculosis and again found a 
close correlation between the vital capacity and the clinical condi- 
tion of the patients. In arrested cases the vital capacity was very 
near the normal value. Scattered observations have been made on 
the vital capacity in other pulmonary conditions such as acute 
bronchitis, emphysema (Wintrich (2), Peabody and Wentworth (7), 
Hoover (18), Siebeck (19)), asthma (Wintrich, Peabody and 
Wentworth), pneumonia (Wittich, Myers, and Jennings (17)), 
pneumothorax (Means and Balboni (20)), and pleural effusion (Pick 
(21), Peabody and Wentworth (7)), but no comprehensive studies 
have as yet been made. In this connection it is of interest that 
Graham (22) has shown that the vital capacity is also of impor- 
tance to the surgeon in the operative treatment of empyema, for, 
used in connection with a mathematical formula devised by him, it 
will indicate approximately the maximum opening in the chest wall 
compatible with life if the mediastinum is not stabilized by adhe- 
sions. 

VITAL CAPACITY AND HEART DISEASE 

With the close relationship which exists between the vital capac- 
ity of the lungs and the production of dyspnea, it is rather curious 
that so little attention has been paid to spirometry in the clinical 
condition in which dyspnea is the most prominent symptom. In 
heart disease dyspnea is perhaps the commonest symptom, and the 
degree of dyspnea or the tendency to dyspnea has always been re- 
garded as a rough index of the severity of the case and the degree of 
circulatory failure. If the vital capacity of the lungs is an expression 
of the tendency to dyspnea, as has already been shown, then it is 
apparent that the vital capacity may also serve as an index of the 



224 PEKING UNION MEDICAL COLLEGE 

clinical condition in patients with heart disease. Many observers 
(Arnold (3), Rubow (23), Bittorf and Forschbach (24), Siebeck 
(19)) have shown that the vital capacity may be decreased in 
heart disease, but it is only within the last few years that the sub- 
ject has been carefully studied at the Peter Bent Brigham Hospital 
and an attempt made to correlate the vital capacity with the 
clinical condition. Briefly, the observations on a large number of 
patients have shown that in the early stages of cardiac disease, when 
there is no evidence of circulatory insufficiency, the vital capacity 
is within normal limits. As the condition progresses and the cardiac 
reserve becomes encroached upon so that physical exertion produces 
undue dyspnea, the vital capacity decreases and the diminution in 
vital capacity parallels very closely the development of the disease. 
If the vital capacity is below 40 per cent of the normal the patients 
are greatly limited and are practically bed-ridden. With a vital 
capacity above 40 per cent of the normal patients can usually be out 
of bed but unless the vital capacity is over 50 per cent they are 
severely handicapped, and even with a vital capacity of 60 to 70 per 
cent they can rarely expect to lead anything but a very quiet life. 
With a vital capacity of 70 to 90 per cent patients can often carry on 
a normal existence limited by the fact that any unusual exertion 
produces dyspnea. The determination of the vital capacity gives a 
good indication of what one may expect a patient to be able to do 
and the information may be obtained while the subject is remaining 
quietly in bed. Its chief value, however, is in following the course of 
the disease and as a guide to treatment. In ambulatory cases of 
heart disease the physical examination usually alters very little 
over long periods of time and opinion as to the course of the disease 
must then be based largely on the patient's recital of his symptoms. 
The most important of these is the tendency to dyspnea and in the 
vital capacity one has a quantitative method of following the devel- 
opment of this symptom. Changes in the vital capacity may occur 
without any objective evidence of cardiac insufficiency such as 
pulmonary edema, tender liver, or swelling of the ankles. It may 
thus be an early indication for active treatment. In severely decom- 
pensated cases, such as one finds in a general hospital, the vital 
capacity is very low, but with satisfactory treatment it will rise 



MORNING ADDRESSES 225 

quickly. West and Pratt (25) have shown the value of spirometry in 
following cases after the administration of digitalis. It is of particu- 
lar interest in cases with a regular cardiac rhythm in which there is 
little effect on the heart rate, for the alterations in vital capacity 
are one of the best indices of the effect of digitalis in promoting 
clinical improvement. Charts on which the vital capacity is plotted 
from day to day give an excellent graphic record of the course of the 
disease. With improvement in the circulatory condition, the vital 
capacity rises; if the situation becomes worse, it falls; and if the 
condition remains stationary, the vital capacity does not change. 
Thus, after days or weeks of treatment one has a graphic record of 
the course of the case which is of distinct aid in prognosis, and which 
gives more definite information as to the functional condition of the 
patient than do any of the other records which are customarily kept. 
In the later stages of heart disease it is easy to see what may cause 
a reduction in the vital capacity of the lungs. General physical 
condition, pulmonary edema, pleural effusion, hepatic enlargement, 
and analogous conditions will all effect the movability of the lungs, 
but the decrease in the early stages, before any physical signs 
develop, is less easy to understand. Many years ago Professor von 
Basch of Vienna suggested that cardiac dyspnea is due to "Lungen- 
starrheit," or pulmonary rigidity resulting from congestion of the 
pulmonary vessels, and last winter Professor Drinker, Dr. Blum- 
gart, and I were able to prove experimentally (26) that engorgement 
of the pulmonary circulation interferes with the entrance of the air in- 
to the lungs. The experimental conditions simulated so closely those 
which obtain in certain types of heart disease that the results can be 
safely interpreted as explaining the clinical findings, and it seems 
clear that the important factor underlying the decrease of the vital 
capacity of the lungs in early cases of cardiac disease is the circula- 
tory disturbance. It is thus evident that observations on the vital 
capacity give us an insight into the condition of the pulmonary 
circulation. The practical significance of this is obvious, for in most 
cases of heart disease the earliest symptoms of circulatory failure 
are referred to the respiration and suggest disturbances in the pul- 
monary circuit, dyspnea precedes peripheral edema. Thus we have 
in the determination of the vital capacity of the lungs a means of 

16 



226 PEKING UNION MEDICAL COLLEGE 

obtaining information about this fundamentally important area of 
the circulation which cannot be obtained in any other way. 

CONCLUSION 

Such, then, briefly sketched, is the present relation of spirometry 
to clinical medicine. The development of more modern methods for 
the study of disease has resulted in the overshadowing of what was 
once regarded as a useful aid to diagnosis and prognosis, but none 
of the newer procedures gives the same type of information as is 
obtained from observations on the vital capacity of the lungs. With 
the general interest now manifested in the disturbances of physio- 
logical functions in disease, it is probable that the mechanism of the 
external respiration will receive its share of attention, and as an 
index of the ventilatory function of the lungs, the determination of 
the vital capacity will be of much value. 

Recent investigations have brought out somewhat improved 
normal standards with which to compare the variations of the 
vital capacity in disease; they have broadened the clinical applica- 
tion of the method and have increased our understanding of the 
physiological significance of the vital capacity of the lungs, but the 
fundamental work of John Hutchinson has stood the test of time. 
It is a model exposition of scientific work, and the concluding sen- 
tences, which indicate the greatness of the author, might well serve 
as a text for all investigators. "The matter of this communication," 
he says, "is founded upon a vast number of facts — immutable 
truths which are infinitely beyond my comprehension. The deduc- 
tions, however, which I have ventured to draw therefrom, I wish to 
advance with modesty, because time, with its mutations, may so 
unfold science as to crush these deductions, and demonstrate them 
as unsound. Nevertheless, the facts themselves can never alter, nor 
deviate in their bearings upon respiration — one of the most im- 
portant functions in the animal economy." 

BIBLIOGRAPHY 

i. Hutchinson, J., Med.-Chir. Tr., London, 1846, xxix, 137. 

1. Wintrich, M. A., Virchow's Handb. d. spec. Path. u. Tberap., 1854, v, I. 

3. Arnold, F., Ueber die Athmungsgrosse des Menchen, Heidelberg, 1855. 



MORNING ADDRESSES 227 

4. Waldenburg, L., Die Pneumatische Behandlung der Respirations- und Circu- 

lationskrankheiten im Anschluss an die Pneumatometrie und Spirometrie, 
2nd edition, Berlin, 1880. 

5. Lundsgaard, C, and Van Slyke, D. D., J. Exper. M., 1918, xxvii, 65. 

6. West, H. F., Arch. Int. Med., 1920, xxv, 306. 

7. Peabody, F. W., and Wentworth, J. A., Arch. Int. Med., 1917, xx, 443. 

8. Dreyer, G., Lancet, 1919, ii, 227. 

9. Du Bois, D., and Du Bois, E. F., Arch. Int. Med., 1916, xvii, 863. 

10. Peabody, F. W., and Sturgis, C. C, Arch. Int. Med., 1921, xxxviii, 501. 

11. Heald, C. B., and Thomson, B., Lancet, 1920, ii, 736. 

12. Levine, S. A., and Wilson, F. N., Heart, 1919-20, vii, 53. 

13. Adams, F. D., and Sturgis, C. C, Am. J. M. Sc, 1919, clviii, 816. 

14. White, P. D., Am. J. M. Sc, 1920, clix, 866. 

15. Garvin A., Lundsgaard, C, and Van Slyke, D. D., J. Exper. M., 191 8, xxvii, 

87. 

16. Dreyer, G., and Burrell, L. S. T., Lancet, 1920, i, 1212. 

17. Wittich, F. W., Myers, J. A., and Jennings, F. L., J. Am. M. Assn., 1920, 

lxxv, 1249. 

18. Hoover, C. F., Arch. Int. Med., 1913, xi, 52. 

19. Siebeck, R., Deutsches Arch./, klin. Med., 1910, c, 204. 

20. Means, J. H., and Balboni, G. M., J. Exper. M., 1916, xxiv, 671. 

21. Pick, A., Ztschr.f. klin. Med., 1889, xvi, 21. 

22. Graham, E. A., J. Am. M. Assn., 1920, lxxv, 992. 

23. Rubow, V., Deutsches Arch. J. klin. Med., 1908, xcii, 255. 

24. Bittorf, A., and Forschbach, J., Ztschr.f. klin. Med., 1910, lxx, 474. 

25. West, H. F., and Pratt, J. H., J. Am. M. Assn., 1920, lxxv, 77. 

26. Drinker, C. K., Peabody, F. W., and Blumgart, H. L., J. Exper. M., 1922, 

xxxv, 77. 



THE ORIGIN OF BLOOD-CELLS* 
By 

Florence R. Sabin, M.D. 

INTRODUCTION 

In 1920, the writer published an account of a study of the origin 
of the vascular system as it can be made out by watching the living 
chick blastoderm of the second day of incubation. The method of 
the origin of vessels can be made out in such specimens, in the area 
pellucida of the yolk-sac, in stages which range from the time just 
before the first somite through the stage of about twenty somites. 

In the area pellucida there are three well-known layers, the 
ectoderm, the double layer of the mesoderm lining the extra-em- 
bryonal ccelom, and the endoderm. The blastoderms are mounted 
in a hanging drop preparation, in Locke-Lewis solution, with the 
endoderm against the cover-slip. The area pellucida is so thin that 
the endoderm, the vascular zone between the endoderm and meso- 
derm, and the mesoderm can all be analyzed with an oil immersion 
lens. The technique was described in 1920 (1). 

BLOOD-VESSELS 

Blood-vessels begin by the differentiation of a new type of cell 
from mesoderm. This cell moves out of the mesoderm, develops a 
dense, basophilic, azurophilic cytoplasm and becomes physically 
more refractile than mesoderm. As soon as this cell divides, it shows 
its essential characteristics, namely, the tendency of the cells to stay 
together to form syncytial masses. These masses of cells put out 
sprouts by which they join similar masses to form a plexus. While 
such solid clumps are still isolated, and after the plexus is formed, 
the cells become transformed into vessels by a liquefaction of the 
central part of the mass to form blood-plasma, while the periphery 
differentiates into endothelium. 

* This paper was subsequently published under the title of, "Studies on 
blood: the vitally stainable granules as a specific criterion for erythroblasts 
and the differentiation of the three strains of the white blood-cells as seen in the 
living chick's yolk-sac." Johns Hopkins Hosp. Bull., 1921, xxxii, 314. 

228 




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MORNING ADDRESSES 229 

There is a progressive differentiation of angioblasts, beginning in 
the periphery of the area vasculosa at the stage of two somites; the 
cells gradually appearing nearer and nearer the embryo, until, at the 
stage of five or six somites, angioblasts differentiate in the axial line 
of the embryo as forerunners of the endothelium of the heart and 
aorta. The heart, aorta, and main vessels of the embryo differen- 
tiate in situ from angioblasts, and increase by the addition of newly 
differentiated cells as well as by the cell-division and by the sprout- 
ing of their endothelial walls. The amount of the differentiation of 
new cells grows progressively less but at what stage it ceases is not 
known. There is thus established the fundamental morphology of 
the vascular system. 

Blood-vessels arise by the development of a new type of cell, 
the vasoformative cell of Ranvier, or the angioblast of His. This 
cell produces the first fluid of the blood; thus, endothelium is pri- 
mary and blood-plasma secondary. Since there is a tissue fluid before 
angioblasts arise, endothelium is from the start a membrane be- 
tween two different fluids, tissue-fluid and plasma. Moreover, the 
process of liquefaction is intracellular, that is, it can be seen in 
chains of single angioblasts which become vessels and it can also be 
seen to take place in the sprouts which are processes of cells, hence 
the lumen of vessels is embryologically intracellular and thus not a 
tissue-space. 

In the living chick of the second day, it can be seen that both 
angioblasts and the endothelial cells give rise to red blood-cells. 
Erythroblasts begin in the chick in the vessels of the outer margin 
of the area opaqua in the stages of from seven to eleven somites. In 
the area pellucida, where they can be seen in the living specimen, 
angioblasts differentiate during the stages of from five to eleven 
somites, while the vessels form and erythroblasts begin during the 
stage of from eleven to fourteen somites. The heart begins to beat 
at the stage of ten somites and the circulation starts when the chick 
has sixteen to seventeen somites. 

During the past year, I have been continuing these studies on the 
living chick, and have found that it is possible to mount the entire 
blastoderm on a large cover-slip, one measuring 42 by 50 mm., 
throughout the third and fourth days of incubation. The cover- 



230 PEKING UNION MEDICAL COLLEGE 

slips must be entirely free from grease or the membrane will not 
flatten out on the glass. From the fifth day on, the chick is too heavy 
to mount in the hanging-drop form, but if the specimen be trans- 
ferred to a dish of Locke-Lewis solution, the amnion can be opened, 
the allantois pushed aside and the yolk-sac cut off close to the em- 
bryo and then spread out and mounted. The circulation, of course, 
stops but the membrane can be mounted and kept alive certainly 
for from three to five hours. So far, I have studied these living mem- 
branes only through the first seven days of incubation. It is an ad- 
vantage to mount the chick with the membranes because the prepa- 
rations are all fixed after the vital studies have been made and many 
of them are stained and mounted in toto. If the embryo has been 
left attached, it can be cut off in the alcohol and then the entire 
ectoderm can be dissected off from the area vasculosa. The speci- 
men is thus made thinner and much easier to analyze. When the 
embryo has been cut away at the start, the ectoderm clings too 
closely to the specimen to be taken off and makes one more layer of 
stained cells in the final specimen. 

I have found it a great advantage to study the embryos with a 
vital dye and add i to 3 drops of a 1 per cent aqueous solution of 
neutral red to 10 cc. of the Locke-Lewis solution, making a dilution 
of possibly 1 to 10,000 of the dye, or less. This may be termed the 
physiological dilution of the dye. 

After the specimens have been studied, they are fixed by floating 
the cover-slip, embryo down, on Bouin's picroformal, and are then 
kept in 70 per cent alcohol until all the picric acid is removed. 
They are then stained in hematoxylin and counterstained in eosin 
with a little orange G. This fixation is excellent for the granulocytes, 
but quite worthless for the erythrocytes after the primitive stage. 
After fixation in Bouin's solution the young erythrocytes show only 
a widemeshed reticulation having no relation whatever to any of the 
substances that can be made out in the living cell. No fixation of the 
blastoderms is adequate to follow the changes in the red cells, but 
they can be identified best after fixation in the vapor of formalin if 
not applied too long. I use it for from ten minutes to half an hour. 
In this the hemoglobin is well preserved but not the basophilic cyto- 
plasm and indeed the earliest traces of hemoglobin which can be 



MORNING ADDRESSES 231 

seen in the living cell by a distinct yellow color cannot be detected 
in the fixed specimens. Helly's fluid, which preserves the basophilic 
substance better, cannot be used, because the blastoderms float off 
from the cover-slip almost immediately and wrinkle so that they 
can never be studied as a section with an oil immersion lens. 

In connection with the study of these blastoderms, a drop of blood 
is drawn from the vessels when the egg is first opened and used for a 
film. These films of blood are studied vitally by Pappenheim's 
method. They are made as follows: A clean glass rod is dipped into 
a dye and drawn across a perfectly clean glass slide. The two dyes 
which I have used are neutral red and brilliant cresyl blue, made up 
either in a 1 per cent aqueous solution or in a saturated alcoholic 
solution. The even film of the stain dries quickly and its strength is 
estimated by the color. The film must not be dense enough to stain 
any nuclei. A drop of blood is then drawn out with a fine glass can- 
ula, placed on a cover-slip which is then inverted on the film of stain, 
ringed at once with salvoline, and placed in a warm box. The vital 
stains develop slowly, on an average in ten minutes, and if perma- 
nent preparations are wanted, the specimen is watched under an oil 
immersion lens until the staining is best, then the cover is drawn off 
from the slide and the film of blood counterstained with one of the 
blood stains. I have used Wright's eosin-methelene blue. In blood 
from chicks on the second and third days of incubation the amount 
of the specific substance of the early red cells, or megaloblasts, 
stainable in the vital dye is so massive that it is necessary to differ- 
entiate the specimens after staining by Wright's method. This can 
be done in absolute alcohol and the decolorizing stopped with xylol. 
The white cells are so very unevenly distributed in the vessels of 
the early blastoderms that no film of blood represents adequately 
the amount of differentiation for this stage. Hence, each stage must 
be studied by both methods, by a survey of the total area pellucida 
and by drops of blood with specific stains. 

In these studies, it can be seen that there are three different 
strains of blood-cells: first, those that arise from endothelium, 
which include both the red cells and the monocyte strain of the 
white cells; second, the granulocytes; and third, the lymphocytes. 
The red cells begin to differentiate on the second day of incubation. 



232 PEKING UNION MEDICAL COLLEGE 

On the third day the endothelium gives rise to the monocytes, that 
is, to the large mononuclears and the transitional forms of Ehrlich. 
In two different specimens I have seen an occasional monocyte on 
the second day but the process becomes active only on the third 
day. The group of the monocytes of the blood is especially well illus- 
trated by Pappenheim on his Plate i (a), as the third row of cells, 
and as the fourth and fifth rows on Ferrata's Plate 12 (3). 

At the same time that the endothelium gives rise to the mono- 
cytes, namely, beginning on the third day, it gives rise to a much 
more numerous extravascular group of cells, identical with the 
monocytes, which are the clasmatocytes of the connective tissues. 
On the third day also the granulocytes begin to differentiate as a 
new type of cell from the mesoderm. These cells develop a specific 
type of granulation and wander into the blood-vessels. The third 
strain is the lymphocytes. These I have never seen differentiating in 
the wall of the yolk-sac, but they begin to appear in the blood- 
stream on the fourth day, but do not become marked until the fifth 
and sixth days. It may be that they arise only within the embryo 
itself. 

ERYTH ROB LASTS 

In these studies it has been possible to establish a criterion for a 
primitive red cell. As was discovered by Pappenheim (4) , the primitive 
red cell has a basophilic, azurophilic cytoplasm so finely granular as 
to appear like ground glass. Fixed to show this basophilic cytoplasm, 
the cell looks like a single angioblast. In the living cell a droplet of 
yolk is occasionally to be seen. If, however, one stains the cell supra- 
vitally with either neutral red or with brilliant cresyl blue, there 
appears a very massive granulation which at first completely fills 
the cell. This granulation is completely soluble in alcohol and in all 
of the usual fixatives, it disappears also in the vapor of formalin. If, 
however, it be stained with neutral red or with brilliant cresyl blue, 
it becomes insoluble in methyl alcohol and hence can be seen in films 
stained with Wright's eosin-methelene blue. For these double stains 
brilliant cresyl blue is slightly better. This special granulation is then 
very easy to bring out in films of blood. It is not so easy to stain in 
the total blastoderm, because the dilution which stains the neutral red 
granules of endothelium, the yolk and all of the stainable substances 



MORNING ADDRESSES 233 

of the clasmatocytes, that is, the dilution of 1 to 10,000, is too dilute 
to stain the granulation of the reds, but it does, nevertheless, make it 
just visible. The primitive red cell in the living blastoderm can be 
stained, however, by injecting the dye directly into the blood-stream; 
or if a drop of a 1 per cent solution of neutral red is put on the blasto- 
derm for a few seconds and then washed off with clear Locke-Lewis 
solution, the red cells show the stain well. 

The question must come up as to whether the stainable substance 
actually exists in the living cell in some state from which it is pre- 
cipitated by the dye, just as Mott has shown that Nissl substance in 
its stainable form develops only as the nerve cell dies. The criterion 
I have used for the actual death of the cell is whether the nucleus 
stains or not, and this specific substance does stain in dilutions which 
do not stain the chromatin of the nucleus at all; the exact dilution 
necessary to stain it must be worked out. When Israel and Pappen- 
heim (5) first described the vital staining of substances in erythro- 
cytes, they thought that the staining commenced only as the cell 
began to die. This may be true. 

For the permanent films of blood on the second and third days, 
the granulation is so dense that after counterstaining with Wright's 
stain, the cells must be differentiated in absolute alcohol, the decolor- 
ation being stopped with xylol. 

On the second and third days the red cells being megaloblasts, 
both the granulation and the basophilic cytoplasm completely fill 
the cell. On the fourth day a narrow rim of clear cytoplasm appears 
in many of the cells, showing hemoglobin around the edge free from 
granules, while the granules make a very dense rosette or wreath 
around the nucleus. These rosettes are very characteristic and in 
stained preparations they greatly obscure the nucleus. By the fourth 
day the red cells have no longer the somewhat uniformly round 
shape of the earlier stage and there is no longer a comparative 
uniformity in size, but rather there are many much larger forms to- 
gether with many small irregular or oval cells. This period of great 
variation in size is a stage of active division of the cells as well as of 
growth of individual cells. In the small oval cells, the rosettes are oval 
and in division the rosettes divide, so that each daughter nucleus 
is surrounded by a wreath of granules before the cells separate. 



234 PEKING UNION MEDICAL COLLEGE 

On the fifth day a few of the red cells begin to show a diminution 
of the granulation, some of the cells grow much larger and the gran- 
ules and rods begin to spread out into the cytoplasm, the cells show- 
ing the polychromasia and the reticulation which is known to be 
characteristic of the so-called reticular forms occurring in anemias in 
human blood. By the seventh day there are large numbers of the 
cells in the reticular stage, while there are still many of the primitive 
cells and the wreath forms. Gradually the amount of the basophilic 
cytoplasm and of the vitally stainable granulation decreases while 
the hemoglobin increases. Finally, the basophilic cytoplasm disap- 
pears, but a small amount of the specific granulation remains in each 
erythrocyte. At the time of hatching and for three days afterwards, 
all of the red cells in the circulating blood show from one to eight or 
ten vitally stainable granules. I have not carried the studies further 
nor studied the stages between the seventh day of incubation and 
the time of hatching. It is clear, however, that one can work out the 
types of cells that are characteristic for each stage of the developing 
chick. Of course at any stage there are some cells characteristic of 
preceding stages. On the second day only the primitive stage is 
present and then with a given increment of time the different stages 
in the development of this specific granulation are added. When 
such a study has been made for a mammalian form and especially 
for the human embryo, as is now feasible, we shall be in a position to 
estimate just how primitive are the cells that appear in the circula- 
tion in anemias. 

The first account of the staining of the specific granulation of the 
red cells which I have been able to find is in a paper by Israel and 
Pappenheim (5) in 1 896, in which they say that if a few dry grains of 
neutral red are placed on a slide and used for a film of fresh blood, 
there will appear a granulation in some of the red cells just as the cell 
begins to die. In 1901, Bettmann (6) described the use of vital neutral 
red in the staining of red cells in pathological conditions, but did not 
discriminate between a staining of the nuclei and the specific granu- 
lation around it. Three years later, Rosin and Bibergeil (7 and 8) 
described the methods of vital staining and the dyes to be used, but 
it was not until 1907, that we have a clear account of the vitally 
stainable granulation of the red cells. In 1907, there appeared three 



MORNING ADDRESSES 235 

papers in the Folia Haematologica, one by Cesaris-Demel (9), one 
by Pappenheim (10), and one by Ferrata (11), in which the vitally 
stainable granules were described and illustrated. Cesaris-Demel 
showed the stage of the wreath around the nucleus, not, however, in 
as primitive a stage as on the fourth day of incubation in the chick. 
He showed also the reticular stages and the final stage of a few 
granules. He distinguished between the deeply staining granules 
and the more faintly staining filaments. 

The primitive basophilic cell, which is the first red blood-cell, was 
first differentiated by Pappenheim (4) and called the megaloblast. It 
has a basophilic cytoplasm, and a large nucleus, poor in chromatin 
and with a conspicuous nucleolus. All the stages of the development 
of this cell as far as concerns the decreasing of its basophilic cyto- 
plasm, the increasing of its content of hemoglobin, and the changes 
of its nucleus have been worked out with the eosin-azur technique in 
final perfection by Pappenheim (2), Ferrata (3), Danchakoff (12), 
Maximow (13), and Weidenriech (14). The development of this cell 
with reference to its specific granulation is now necessary to com- 
plete its life history. 

In the chick, it has been shown that all of the primitive blood- 
cells are megaloblasts which become erythroblasts as soon as a trace 
of hemoglobin can be made out. These cells are derived from angio- 
blasts and from endothelium. As far as the specific granulation is 
concerned, the first stage, on the second and third days of incuba- 
tion, has the granulation throughout the cell; from the fourth to the 
sixth day, there are the rosette or wreath forms in which the granu- 
lation is around the nucleus. On the seventh day the reticular forms 
begin. All these stages show diffuse basophilia. It will be possible to 
tell with further studies just when basophilia and the reticular forms 
disappear in the majority of the red cells. At the time of hatch- 
ing all of the cells in the circulation have acidophilic hemoglobin- 
bearing cytoplasm with a few vitally stainable granules. It is of 
course clear that at any stage in development, while the majority of 
the cells are in a specific phase, a few of the earlier types may be 
found. In normal human blood about 1 per cent or less of the 
erythrocytes show a few vitally stainable granules. 

The question which must come up first in connection with this 



236 PEKING UNION MEDICAL COLLEGE 

granulation is its relation to the so-called basophilic punctation, and 
both Pappenheim (2) and Ferrata (3) agree that these two sub- 
stances are entirely different. The basophilic punctation stains in 
azur after fixation. Ferrata thinks that it is an abnormal clumping, 
"conglobation," of the azurophilic cytoplasm and he shows the grad- 
ual production of the punctate forms in red cells after experimental 
lead poisoning on his Plate 8. It is thus easy to see why basophilic 
punctation does not occur in embryonic blood, while the vitally 
stainable granulation is on the other hand specifically characteristic 
of development. 

Another point in which this specific granulation may prove of 
interest is that it offers a chance to study the development of hemo- 
globin in the cell by testing the granulation for the presence or the 
absence of iron. Both the azurophilic cytoplasm and the granulation 
disappear as hemoglobin develops, but the granulation alone is 
characteristic of the red cell as distinct from all other blood-cells. 

In the developing blood there are always a few cells containing the 
Howell-Jolly bodies. These are fragments of nuclei staining just like 
chromatin, which were discovered by Howell (15) in 1890, in a study 
of the blood of the cat after hemorrhage. Of course the corpuscles of 
the chick are all nucleated, so that the question of the extrusion of 
nuclei does not come up, although an occasional cell, from the very 
beginning of the formation of blood on the second day, shows a 
fragmented nucleus. I interpret such cells as dead. They are to be 
found in the early blood islands before the cells become free and are 
very interesting as showing that cell death occurs in the early stages 
of marked cell division and growth. 

ORIGIN OF MONOCYTES AND CLASMATOCYTES FROM ENDOTHELIUM 

The separation of the clasmatocytes as a distinct type of cell of 
the connective tissues is due to Maximow (16). He showed that by 
introducing two sterile cover-slips under the skin in rabbits, one 
could separate three types of cells by the speed with which they 
passed between the covers, leucocytes appearing first, a special cell, 
the clasmatocyte, wandering in during the first nineteen hours, and 
the fibroblast in from two to four days. Then he showed that the 
clasmatocyte was specifically sensitive to neutral red (17), while 



MORNING ADDRESSES 237 

Bouffard (18), Goldmann (19 and 20), Evans (21 to 24), Schule- 
mann (22 to 24), and a large group of workers have demonstrated 
that it is the cell of the connective tissues most specifically differ- 
entiated to phagocytize and store particulate matter. The specific 
reaction of vital neutral red to this cell is that the dye stains certain 
granules of the cell and certain large fluid spheres which are called 
vacuoles, the so-called "neutral red granules and vacuoles" of Lewis 
and Lewis (25). These vacuoles are organs into which the cell passes 
phagocytized particulate matter. In the vacuoles the fine particles 
which the cell has taken up become clumped and, as Evans and 
Scott (26) have shown, may even be recrystallized. 

Aschoff and Kiyono (27) then showed that an identical reaction 
to a vital dye could be obtained by certain cells of the blood, namely 
the group Naegeli (28) has called the monocytes, which are the large 
mononuclear and transitional forms of the Ehrlich school. Thus they 
distinguished and related histiocytes of the blood and histiocytes of 
the connective tissues. Moreover they regarded the histiocytes of the 
blood as of endothelial origin. 

Pappenheim (2) and Ferrata (3) have illustrated the separation of 
the monocytes, the leucocytes, the lymphocytes, on purely morpho- 
logical grounds, believing that there is a common stem cell, a hypo- 
thetical hematoblast for them all. Aschoff and Kiyono separate the 
monocytes, calling them histiocytes of the white cells on a physio- 
logical basis, and I think that I can demonstrate on a fundamental 
embryological basis that the monocyte and clasmatocyte are iden- 
tical cells, derived from endothelium and making one of the three 
great groups of connective tissue cells that contribute to the blood. 

If a blastoderm of the third day of incubation be stained in vital 
neutral red, the endothelium stands out with numerous granules 
staining in the dye which are both around the nuclei and scattered 
in the thin periphery of the cytoplasm. The endothelium of the 
capillaries and the veins often becomes reduplicated. Endothelium 
is more refractive than mesoderm, and this characteristic, as well as 
the staining of the granules with neutral red, characterizes both of 
these layers of endothelium. One of the cells of the inner row can 
then be seen to enlarge, protrude into the lumen, and develop the 
vacuoles which are characteristic of clasmatocytes. The periphery 



2 38 PEKING UNION MEDICAL COLLEGE 

of the cell then puts out a film of cytoplasm in which there is a 
central process more refractile than the rest and these films are in 
constant motion. In fact the eye is attracted to these cells both by 
the stained vacuoles and by the motion of the peripheral films of 
cytoplasm. Such a cell then gradually becomes free. The characteris- 
tic motion of the peripheral films continues, keeping the surround- 
ing fluid moving, though the cell itself shows very little locomotion. 
In the study of the origin of the red blood-cells on the second day 
of incubation (i) it was noted that the erythroblasts formed great 
clumps of cells attached to the inner surface of a complete endothe- 
lium. The monocytes, on the other hand, differentiate and drop off 
as single cells, leaving the original endothelial cell from which they 
came as the wall of the vessel. 

An endothelial cell may become phagocytic while it is yet in place, 
for I have seen them with red cells engulfed just as Maximow (13) 
shows for a mammal in his Figure 4 on Plate 18. This means that an 
endothelial cell which is actually a part of the wall of a vessel, not one 
of the reduplicated forms already on the road toward becoming free, 
may be phagocytic. That is to say, endothelium is itself phagocytic, 
and has, as well, the power to give off free cells which are phagocytic. 
In the same figure quoted above, Maximow shows three free mono- 
cytes, very characteristic, labeled Edph. He recognized them as 
desquamated endothelium but did not identify them as monocytes. 
In fact all of the early stages of the development of blood are beauti- 
fully illustrated on the two plates of Maximow in this article. 

While these few cells are becoming free in the lumen of the vessel 
to make the monocytes of the blood, the outer row of the redupli- 
cated endothelium divides rapidly in irregular patches, giving the 
outlines of the vessels an exceedingly irregular contour, very differ- 
ent from the smooth contour of the earlier capillaries and from the 
wall of the omphalomesenteric arteries which now have a single 
layer of smooth muscle. The clumps of cells along the outer wall of 
the vessel develop the vacuoles characteristic of clasmatocytes and 
become free as clasmatocytes. Many hundreds of the extravascular 
cells are formed from the endothelium to one intravascular. The 
extravascular forms tend to be larger and have larger vacuoles, but 
I have seen one of the larger cells wander into a vessel. The original 



MORNING ADDRESSES 239 

endothelium has granules that stain in neutral red; it may also have 
vacuoles. The free cells all have both vacuoles and granules and a 
differentiation of the periphery of the cell into motile films. Studied 
with vital neutral red, the monocytes and the clasmatocytes are 
conspicuous because they are stained. 

Thus, in the early chick, endothelium gives rise to two groups of 
cells, the megaloblasts which develop hemoglobin and become 
erythroblasts and a strain of cells termed histiocytes by Aschoff. 
The extravascular histiocytes have been termed clasmatocytes, and 
the intravascular, monocytes. They are identical and are specifically 
differentiated along the line of phagocytosis. They take up particu- 
late matter and debris in solid form which they segregate and store 
in certain preformed vacuoles filled with fluid. They do not store 
this insoluble material permanently because it is gradually returned 
to the circulation and excreted by the kidney. So they represent a 
mechanism for taking care of foreign matter in excess of the amount 
that the body can excrete at the time. In the blastoderms from the 
third to the seventh day there is comparatively little differentiation 
of new angioblasts in the area pellucida. In fact, in about fifty 
specimens, I have found only three masses of solid angioblasts. The 
hollow isolated vesicles made from these solid masses are, however, 
more numerous, indicating that this stage lasts longer than the solid 
stage. In one specimen of the third day of incubation there was a 
long mass of solid angioblasts which started to liquefy to form a ves- 
sel, and while the center of the mass was liquefying to form a vessel, 
two cells wandered off from the periphery as clasmatocytes. Thus 
angioblasts can also give rise to clasmatocytes. 

If one takes the group of monocytes as they are shown in the third 
row of Pappenheim's Plate 1 (2), and in the fourth and fifth rows of 
Ferrata's Plate 12 (3), it will be seen that the group includes all of 
the large mononuclear forms and the transitionals of the circulating 
blood. Both of these types can be seen early in the chick coming from 
endothelium; an endothelial derivative which is larger and less vacu- 
olated is the mononuclear cell, a smaller and more vacuolated type, 
the transitional. The transitional is thus shown to be a finished type 
of cell like the cell of the adult form, for which the term transitional 
is therefore a misnomer. The large mononuclear type always has an 



2 4 o PEKING UNION MEDICAL COLLEGE 

excentric nucleus; it is distinguished most easily in the films of blood, 
stained with brilliant cresyl blue and counterstained with eosin- 
azur. It lacks the specific granulation of the erythroblast and has a 
very clear distinctive blue cytoplasm in Wright's blood-stain. With 
the group of the clasmatocyte in the connective tissues, Maximow 
divided the cells into resting and active cells. With the group in the 
blood, it is not wholly clear whether the larger or mononuclear forms 
are resting or are old forms. In the embryo, the large forms appear 
less specifically differentiated. Both forms can be seen in the living 
chick to come from endothelium. Thus the clasmatocytes (histio- 
cytes) are derivatives of endothelium, developed specifically along 
the line of phagocytosis and storing of particulate, solid matter and 
possessing a certain type of motion of the cell in situ and very slow 
locomotion. 

THE GRANULOCYTES, OR LEUCOCYTES 

On the third day granulocytes also begin, represented by the 
cells which are analogous to the neutrophilic myelocyte of mammals. 
In the chick the granulocyte with fine granules is pseudo-eosino- 
philic. The first sign of the beginning of the granulocytes is that a cell 
appears close to a vessel which cannot be distinguished from a sin- 
gle angioblast. I have not found in these cells any substance stain- 
able in neutral red except the specific granulation which stains 
paler than the granule of endothelium, but am not yet entirely sure 
that this will be a sufficient distinguishing mark between this cell 
and a single angioblast. When, however, such a single cell divides 
there is no longer any difficulty because two angioblasts stay to- 
gether while two granuloblasts separate. This criterion is not ade- 
quate when one has sections only, but in watching the living mem- 
branes or in studying them after fixation, where every cell of an 
entire area can be seen in its relations to other cells, it is sufficient. 
Such material has obvious advantages over sections. Thus, from one 
cell comes a clump of four or more cells with a dense azurophilic 
cytoplasm, the stem cell of the monophyletic school, lying near a 
vessel. These cells then show the following changes: The nuclei be- 
come excentric, while the center of the cell is occupied by the cen- 
trosphere made very obvious by the development of fine granules, 
staining pink in neutral red, always arranged in a crescent around 



MORNING ADDRESSES 241 

the centrosome. Thus, there is a nucleus on one side, a clear spot in 
the center of the cell, and on the other side this crescent of fine 
granules. The granules are entirely motionless at the start, there is 
none of the active streaming of the granules which is always asso- 
ciated with amoeboid movement and which must be associated with 
a fluid state of the cytoplasm. The cell itself, however, does move, 
but very slowly, directly toward the vessel. One of the cells reaches 
the wall, half-way between the endothelial nuclei, and then one can 
see the wall bend inward, until finally the cell enters the lumen. 
The rest of the clump line up behind the first and also pass in. Thus, 
these granulocytes show a specific chemotactic reaction at once. 
Throughout these early stages the granules are arranged character- 
istically around the centrosome. Thus, the specific granulation of the 
red cell is arranged around the nucleus, of the granulocyte around 
the centrosome, while the granules of the endothelial cell are scat- 
tered throughout the cell. Even in these early stages the nuclei of 
these cells become indented, the concave side always being toward 
the centrosome, so that the primitive cell may soon be regarded as a 
leucocyte. 

In the case of the monocytes and the clasmatocytes, both of these 
cells can be readily found differentiating and dropping off from the 
endothelium, but no relation to endothelium can be made out in the 
case of the granulocytes. They are near vessels but never form a 
part of their wall. It was shown by Dantchakoff (12) in 1908 that 
the granulocytes are an extravascular cell in origin. 

There are no eosinophils on the third day. The eosinophilic gran- 
ule of the chick's blood is in long rods. During the first seven days 
I have seen only a few in the circulation and have not found them 
differentiating in the area pellucida. Probably further study will 
bring them out, since they are known through the work of Dantcha- 
koff (12) to develop in the area opaqua of the yolk-sac. The mast 
cells I have not seen at all in the first seven days, and Maximow 
(29) found that they develop late in mammals. 

From these observations one may offer the theory that the two 
stem cells, first the angioblasts with their power to give rise both to 
red cells and to histiocytes in the larger sense, and second the granu- 
locytes, are cells whose common ancestor is a mesenchyme cell instead. 

17 



242 PEKING UNION MEDICAL COLLEGE 

of a differentiated stem cell or hematoblast. In other words, the cells 
of the blood are not so sharply marked off from the cells of the con- 
nective tissues as to have a specific, common stem cell. At least one 
would have to prove that the differentiated cells which normally 
made the syncytial masses of angioblasts could be made to develop 
granulocytes. The argument for the mesenchyme cell as the stem 
cell for the three distinct strains of cells which contribute to the 
blood, is that three such groups can be isolated embryologically and 
they correspond to a functional classification. At least one may say 
that no common differentiated stem cell has been adequately 
demonstrated. 

LYMPHOCYTES 

In these studies of the development of blood in a living form, the 
account of the origin of the lymphocytes is very incomplete. The 
lymphocytes make a group of cells ranging in the mammal from the 
size of a red cell up to cells twice the size. Likewise in the chick the 
lymphocytes are the smallest cell. When the cell first appears, all of 
them are of the small size. The cell has a characteristic nucleus and 
its cytoplasm contains a few azurophilic granules, discovered by 
Michaelis and Wolff (30). The living cell has a nuclear membrane 
which is more distinct than in any other cell, but that this criterion is 
a difficult one to go by can be realized readily in connection with the 
fact that all nuclei become distinct as a cell dies. The cytoplasm of 
the lymphocytes contains but few granules and they do not stain 
readily in neutral red, but can be made to do so by increasing the 
amount of the dye or the time of staining. From these facts it is less 
readily discriminated than the other types. The reactions of lym- 
phocytes in tissue cultures have been described by Lewis and Web- 
ster (31). In Wright's stain, the early lymphocytes are exactly as 
distinctive as in adult blood. The first forms are of the small variety. 
I have seen a few on the fourth day, more on the fifth and sixth. In 
the blood smears, they occur in small clumps. The chromatin of the 
nuclei is very dense and has a peculiar violet reaction with eosin- 
azur. I have never found any indication of their differentiation in 
the area pellucida, thus it may be that they form only within the 
embryo itself rather than in the yolk-sac. However, a more extensive 
study of the yolk-sac may bring them out. All of the evidence from 



MORNING ADDRESSES 243 

the study of this cell in the adult is that it differentiates extravas- 
cularly from reticulum. The only evidence, then, of significance in 
these studies in regard to this cell is that it occurs later than the 
other two groups and hence should not be regarded as a stem cell. 
Thus, from these studies, I would stress the use of the three names of 
white cells as specific for the three distinct groups, the leucocytes, 
the monocytes, and the lymphocytes. 

In these studies it is very plain that each white cell, as it first ap- 
pears, is differentiated; while the red cells pass through a long stage 
of maturation. The first erythroblasts can be told as early stages 
of the red cells by a specific granulation, but the cell itself passes 
through a long series of stages before it is the erythrocyte of the 
adult blood. Of the white cells, the monocytes are a phagocytic 
type, like the cells of the adult before they leave the wall of the 
vessel, the endothelium itself being phagocytic; the granulocytes 
develop their specific type of granulation early and soon begin 
to be leucocytes, and the first lymphocytes are distinctive. When, 
however, all of these three types of white cells begin to divide, 
the discrimination of all of the young cells is by no means easy, 
as the entire history of hematology attests. From this it can 
readily be seen that one must continue these studies of the de- 
velopment of blood in these living forms, watching especially the 
young cells just after division in all the stages of incubation, before 
one can adequately master all of the types of cells that are to be seen 
in bone marrow. In a drop of blood taken on the third day of incu- 
bation it is possible to tell all the cells apart, — later it becomes 
most difficult. It is the study of the maturation stages of each group 
of cells by means of the eosin-azur technique that has been the great 
contribution of the monophyletic school. To this study must now be 
added certain specific criteria that come out through the method of 
applying dyes to living cells; and we must now follow the stages of 
the cells with these vital dyes through the different embryonic 
periods. 

The postulation of three strains of blood-cells on the basis of em- 
bryology fits in with the functional groups as we now know them. 
The endothelial or angioblastic group represents first the hemoglo- 
bin-bearing cells, and second that group of the blood-cells which 



244 PEKING UNION MEDICAL COLLEGE 

exhibit a special property of endothelium, namely phagocytosis. 
The monocytes have this power of phagocytosis, they possess a 
peculiar type of motion in situ with very slow locomotion. The 
granulocytes possess a high degree of amceboid motion, with speed 
and a flowing of the granules. They respond to chemotactic influ- 
fluences, are also phagocytic, and have functions probably related to 
their specific granulations. The lymphocyte strain, as Murphy (32 
to 34) has shown, are separated off physiologically by their being 
more sensitive to X-rays and to the emanation of radium than 
other normal cells. Moreover, he has shown that they are related 
to immunity toward certain forms of tumors as well as to certain 
types of infection. 

The study of the blood-cells is a part of the study of the cells of 
the connective tissues. The erythrocytes are the only type that 
function only within the vessels. Of the other group from endothe- 
lium, the histiocyte in the larger sense, the vast majority make the 
clasmatocytes of the connective tissues, which are the mononuclear 
forms and the actively phagocytic forms of subacute infection, the 
resting and active wandering cells of Maximow. A few of this group 
make the monocytes, that is, the large mononuclear and transitional 
forms of the blood. Of the granulocytes, which all differentiate ex- 
travascularly, the neutrophilic leucocytes pass into the vessels in the 
largest numbers. Of the eosinophiles very many remain in the tissues, 
while the mast cells never enter the vessels in most animal forms. 
By mast cell is meant a cell of the connective tissues occurring along 
vessels, along nerves, and between muscle fibers, having a special, 
metachromatic, basophilic granule. The so-called mast cell of human 
blood has been shown by Weidenreich (35) to be a degenerating 
cell without any centrosome. The lymphocytes are for the most part 
extravascular, arising in the lymph glands and in the follicles of the 
spleen and in very numerous follicles in the various organs either 
associated with lymphatic capillaries or not. Thus, the differentia- 
tion of three strains of blood-cells, the endothelial strain, the granu- 
locyte strain, and the lymphocyte strain, that can be made out in the 
early stages of the chick embryo, can be shown to correspond with a 
functional grouping as far as we yet know the functions of the types 
of blood-cells. Moreover, the origin of the cells of the blood can be 



MORNING ADDRESSES 245 

shown to be but a part of the study of the great groups of wandering 
cells of the connective tissues, the only type which function only 
intravascularly being the erythrocytes. 

The method of studying blood with vital dyes, beginning with the 
stages of the embryo when the cells first appear, gives a very great 
advantage in following the maturation of specific cells and gives a 
chance of analyzing the complicated young forms which it is neces- 
sary to recognize in order to understand bone marrow. 

The group of the red cells is characterized by a specific granula- 
tion stainable in certain vital dyes, possibly one should say precipi- 
tated by these dyes. This substance is at first throughout the cyto- 
plasm, then in a wreath around the nucleus, then in a reticular form, 
and finally in scattered granules or droplets. The arrangement of 
this granulation around the nucleus should be stressed, although the 
substance is of cytoplasmic not of nuclear origin. Red cells with 
nuclear fragments, Howell-Jolly bodies, can be shown to be dying 
cells. The strains of white cells, clasmatocytes and monocytes, that 
come from endothelium, are characterized by certain granules and 
vacuoles stainable in very dilute neutral red. They are scattered 
diffusely throughout the cells. The granulocytes are characterized 
by the arrangement of their specific granulation with reference to 
the centrosome. The lymphocytes are less sharply characterized 
morphologically, but have somewhat distinctive nuclei and gran- 
ules stainable in azur. 

This work is a part of the new subject of experimental cytology 
which seeks to analyze cells by means of specific criteria and to use 
these criteria to study the reactions of cells to normal and abnormal 
conditions. 

BIBLIOGRAPHY 

i. Sabin, F. R., Contributions to Embryology, Carnegie Inst. Washington, Pub- 
lication No. 272, 1920, ix, 215. 

2. Pappenheim, A., Morphol. hcematol., Bd. i, or Folia hcematol., 1919, xxiii, 533; 
Morphol. hcematol., Bd., ii, or Folia hcematol., 1919, xxiv, i, Plates 1-10. 

3. Ferrata, A., Le Emopatie, Milan, 191 8, i, Parte Generale. 

4. Pappenheim, A., Virchow s Arch. f. path. Anat., 1898, cli, 89. 

5. Israel, O., and Pappenheim, A., Virchow s Arch. f. path. Anat., 1896, cxliii, 

4 J 9- 

6. Bettmann, Micnchen. med. Wchnschr., 1901, xlviii, 957. 

7. Rosin, H., and Bibergeil, E., Ztschr.f. klin. Med., 1904, liv, 197. 



246 PEKING UNION MEDICAL COLLEGE 

8. Rosin, H., and Bibergeil, E., Virchow's Arch. f. path. Anat., 1904, clxxviii, 
478. 

9. Cesaris-Demel, A., Folia hcematol., 1907, iv, Suppl., 1. 

10. Pappenheim, A., Folia hcematol., 1907, iv, Suppl., 46. 

11. Ferrata, A., Folia hcematol., 1907, iv, Suppl., 23- 

12. Danchakoff, V., Anat. Hefte, Abt. I, 1908, xxxvii, 473. 

13. Maximow, A., Arch.f. mikr. Anat., 1909, lxxiii, 444. 

14. Weidenreich, F., Anat. Hefte, Abt. II, Ergebn. d. Anat. u. Entwcklngsgesch., 
1904, xiv, 345. 

15. Howell, W. H., J. Morphol., 1890, iv, 57. 

16. Maximow, A., Beitr. z. path. Anat. u. z. allg. Path., 1901-02, iv-v, Suppl., 1. 

17. Maximow, A., Arch.f. mikr. Anat., 1906, lxvii, 680. 

18. Bouffard, G., Ann. de V Inst. Pasteur, 1906, xx, 539. 

19. Goldmann, Die aussere und innere Sekretion des gesunden Organismus im 
Lichte der "Vitalen Farbung," Tubingen, 1909. 

20. Goldmann, Neue Untersuchungen iiber die aussere und innere Sekretion 
des gesunden und kranken Organismus im Lichte der "Vitalen Farbung," 
Tubingen, 191 2. 

21. Evans, H. M., Am. J. Physiol., 1915, xxxvii, 243. 

22. Evans, H. M., and Schulemann, W., Science, 1914, xxxix, 443. 

23. Evans, H. M., and Schulemann, W., Deutsche med. IVchnschr., 1914, xl, 
1508. 

24. Evans, H. M., and Schulemann, W., Folia hamatol., 1915, xix, 207. 

25. Lewis, M. R., and Lewis, W. H., Am. J. Anat., 1915, xvii, 339. 

26. Evans, H. M., and Scott, Contributions to Embryology, Carnegie Inst. 
Washington, Publication No. 273, 1920, x, 1. 

27. Aschoff, L., and Kiyono, Folia hcematol., 1913, xv, 383. 

28. Naegeli, O., Blutkrankheiten und Blutdiagnostik, Leipzig, 191 2. 

29. Maximow, A., Arch.f. mikr. Anat., 1910, lxxvi, 1. 

30. Michaelis, L., and Wolff, A., J'irchow's Arch. f. path. Anat., 1902, clxvii, 

31. Lewis, W. H., and Webster, L. T., J. Exper. M., 1921, xxxiii, 261. 

32. Murphy, J. B., J. Am. M. Assn., 191 2, lix, 874. 

33. Murphy, J. B., J. Exper. M., 1914, xix, 513. 

34. Murphy, J. B., J. Exper. M., 1916, xxiv, 1. (Complete series of articles in 
J. Exper. M., 191 2-21.) 

35. Weidenreich, F., Arch.f. mikr. Anat., 1908, lxxii, 209. 



OSTEOMYELITIS 
By 

Theodore Tuffier, M.D. 
[outline of the paper] 

Three points were developed: (i) the conditions of pathologic 
physiology; (2) the conditions of pathologic anatomy; and (3) the 
treatment of osteomyelitis. 

I. THE CONDITIONS OF PATHOLOGICAL PHYSIOLOGY IN BONE 

The principal characteristics of infections of bone depend upon the 
structure of the tissue. Its vitality is low, its blood supply relatively 
poor, the nutritive canals are very narrow and inelastic, the ground 
substance is practically impermeable, and its metabolism is very 
slow. These facts explain the frequency of necrosis, the changes in 
the structure of the bone, and the difficulty of therapy in those in- 
fections which are hard to reach and whose real extent it is impossi- 
ble to discover. 

The infection is of local origin after traumata, operations, or in- 
fections. It is of general origin in the septicemias of staphylococcus, 
streptococcus, or typhoid infections. The only remarkable point is 
that certain infective agents very rarely localize in bone, while cer- 
tain forms of staphylococcus osteomyelitis last during the whole life 
of the individual. 

2. THE CONDITIONS OF PATHOLOGICAL ANATOMY 

The macroscopic pathological anatomy is easily seen in the bony 
changes in infected amputation stumps. (Many lantern slides of 
cases of this kind in wounded soldiers were projected. They demon- 
strated terminal osteomyelitis and lateral osteomyelitis — extending 
up the shaft — for a considerable distance from the seat of infection.) 
These two forms must not be confused with the exostoses arising 
from the periosteum which have not the same form nor the same 
location. The former are infections, the latter are faults of the 
operator. 

247 



248 PEKING UNION MEDICAL COLLEGE 

Osteomyelitis is characterized by a complete irregularity of bony 
growth. It is neither compact tissue nor soft tissue, but a production 
of spongy bony tissue in the medullary canal, under the periosteum 
and even outside. This osteitis is several centimeters in length and 
its limits are often irregular. In the lateral sort a newly formed 
bony cylinder extends far up under the periosteum. In certain points 
rarefying osteitis is complicated by necrosis of which one can follow 
the formation. 

3. THE TREATMENT OF OSTEOMYELITIS 

The treatment of osteomyelitis is preventive and curative, surgi- 
cal and medical. In traumatic osteomyelitis the preventive measures 
are operative asepsis and, in amputation, making the flap suffi- 
ciently long to cover the bone completely. Several lantern slides 
showed, in amputations of the leg, the fibula too long and the con- 
sequent hindering of the reunion. The same thing was shown in am- 
putation of the thigh. In such cases it is necessary from the begin- 
ning to use traction on the soft parts. 

The cure of spontaneous acute osteomyelitis in young persons is 
difficult. Surgical treatment by immediate and extensive resection 
leads to relapses. Attempts at autovaccination or stock vaccination 
with staphylococcus and also attempts at "proteinic shock" have 
given very inconstant results, and favorable results, while more 
frequent, are not constant. Some cases have even been cured with- 
out surgical intervention, but their future course is not yet known. 

In chronic osteomyelitis, disinfection of the wound with Dakin's 
solution is long and difficult, and exposed to frequent check, for the 
subjacent infection of the bone cannot be reached, and the organ- 
isms spread to variable distances in the wound. Curettages and the 
resection of the diaphysis as far up as the medullary canal makes 
reinfection liable. The transformation of the suppurating cavity to 
a large flat surface is the best method. If it is aseptic, a graft of living 
muscle with healing by primary intention is often efficacious. 

In cases of osteomyelitis in amputation stumps one ought to re- 
move only a minimum of the infected tissue and not touch the dis- 
tant lateral osteitis which heals by itself. 

In spite of all these methods, osteomyelitis remains the most 



MORNING ADDRESSES 249 

terrible, the most tenacious, and the most rebellious of surgical 
affections of the bone. One must reckon its duration by years, and 
it can never definitely be said that a patient has recovered. 

SUPPLEMENTARY REMARKS 

The factor that makes it difficult to judge the value of vaccina- 
tion in spontaneous osteomyelitis is that the evolution of the dis- 
ease varies greatly in different cases, and that there is not always 
anything in the first symptoms that would make it possible to pre- 
dict the later course of development. Thus certain spontaneous 
osteomyelitis cases grow worse abruptly, with fatal consequences. 
On the other hand, local symptoms apparently serious, may disap- 
pear spontaneously. So when one surgeon reports a case of cure by 
the use of vaccine, another immediately protests, saying that he 
has seen similar cases cured without either vaccination or operation. 

It would seem, however, that in certain varieties of these infec- 
tions very great improvement, if not definite cure, has resulted 
from the use of vaccine. 

It is very difficult to say how long this vaccination affords pro- 
tection, and whether symptoms will not recur, but it may be stated 
as certainty that X-rays taken later would lead to a diagnosis of 
osteomyelitis. It rarely, if ever, happens that an acute osteomyelitis 
does not leave behind it disturbances in the bony structure, a sequel 
which the X-ray would always reveal. The question is whether vac- 
cination performed at the very start of the disease does not check 
the process of the bone lesions shown by the X-ray. The problem is 
a complex one, but, in my opinion, it is moving toward a solution 
favorable to vaccination. 



THE PRESENT STATUS AND FUTURE PROBLEMS 
OF CHEMOTHERAPY 

By 

Sahachiro Hata, M.D. 

INTRODUCTION 

Ever since Ehrlich with Hata published the therapeutic action 
of salvarsan upon spirochetosis as one of the results of his long con- 
tinued study on chemotherapy, the eyes of all the workers in medi- 
cine interested in the treatment of infectious diseases have been 
turned to his new school. Investigation of various chemical prepara- 
tions has been both experimentally and clinically applied in the 
treatment of various diseases in all quarters of the globe. Scientists 
were, at that time, working with so much eagerness and hope that 
Ehrlich expressed his heartfelt wishes before the XVIIth Interna- 
tional Congress of Medicine in London in 1913, in the following 
words: "I might, without being set down as an optimist, put for- 
ward the view that in the next five years we shall have advances of 
the highest importance to record in this field of research." Ehrlich's 
hope was shared by many who expected that before long important 
progress in chemotherapy would be made. Alas for the newly in- 
troduced branch of medical science! In one year or so, the whole 
world became involved in one of the most devastating wars ever 
known. The consequence was that scientific researches and investi- 
gations were abandoned and before the war was over, Ehrlich had 
passed into eternity. Our former hope remains as a hope, now that 
more than five years have elapsed since the death of the leader of 
chemotherapy. But the endeavor of numerous workers in chemo- 
therapy, exerted during the ten years since the discovery of sal- 
varsan, has not been entirely unrewarded, for there has been a per- 
ceptible advance in fundamental research as well as in clinical 
application. 

The first requisite that should be borne in mind in the experi- 
mental work on chemotherapy is that we must know the nature of 
the pathogenic viri and such viri must successfully cause experi- 

250 



MORNING ADDRESSES 251 

mental infection in the animal body. Had there not been the 
brilliant works of Lister, Pasteur, Koch, and many others, Ehrlich's 
results would never have been obtained. Consider, then, the discov- 
ery of the virus and successful experimental animal infection of 
Weil's disease by Inada and his co-workers, the results of the studies 
on yellow fever by Noguchi of The Rockefeller Institute, the re- 
markable achievements of Flexner in the study of poliomyelitis, 
the successful animal inoculation of typhus fever and tsutsugamushi 
disease, which has been attained by various workers. They not only 
contribute to the etiological knowledge of infectious diseases, but 
also to further advances in the immunotherapy or chemotherapy 
by which these diseases may either be cured or the sources of their 
infection eradicated, even though no satisfactory remedies for them 
are yet known. 

Improvements in the preparation of salvarsan have already been 
attempted and successfully made by Ehrlich, who discovered new 
preparations in the form of neo-salvarsan and the sodium salt of 
salvarsan. These two modifications have an advantage over salvar- 
san in the facility of their practical application. They have not been, 
however, improved in their therapeutic indices, which are most 
important in the therapeutic efficacy of any chemotherapeutic 
preparation. Ehrlich has also made studies on the metallic com- 
pounds of salvarsan. It was a few years ago that his successor, Kolle, 
published the fact that, of all the metallic compounds, silver salvar- 
san is the most efficacious. He reports that it has an even better 
therapeutic index than salvarsan, but the results of my tests un- 
fortunately proved that it fell short of expectations. I have also 
tested the silver salts of Japanese-made salvarsan, "arsaminol." I 
have found that it produced no better therapeutic indices than the 
original arsaminol. Quite independently of Kolle's work, I have been 
making comparative studies with more than ninety preparations of 
the gold, silver, mercury, and other metallic salts combined with 
arsaminol, but have not obtained any satisfactory results. Among 
these, by the way, the silver antimonium compound of arsaminol 
has by far the greatest efficacy and sometimes it has proved to have 
better therapeutic indices than arsaminol. It still remains unproved 
whether or not Kolle's silver salvarsan has any practical advantage 



252 PEKING UNION MEDICAL COLLEGE 

over salvarsan with regard to its therapeutic efficacy. I have also 
tried the best preparations of the silver antimonium salts of arsam- 
inol on many cases, but I have not found that they possess any 
remarkable advantages over arsaminol. 

There is, however, one advantage that such metallic compounds 
of salvarsan have: that is, they are more stable than salvarsan, or 
in other words, they are less liable to turn into poisonous substances 
by oxidation or decomposition. Again, Kolle has prepared another 
derivative of salvarsan, which is known by the name of "sulphoxy- 
late." This is said not to undergo any changes even when it is made 
into a solution. I have had as yet no experience with this. Giemsa 
has also prepared a derivative of salvarsan, "arsalyt" or "bis- 
methylamino-tetramino-arsenobenzene," which is said to be effica- 
cious in all forms of spirochetosis, with a very high therapeutic index. 
But I have as yet heard nothing further about the results of its 
practical application. These facts indicate further possible improve- 
ment for the preparations of salvarsan derivatives which have higher 
therapeutic indices and greater facility for practical purposes. 

DISEASES AMENABLE TO SALVARSAN TREATMENT 

When viewed from the clinical standpoint, there has been great 
progress in the range of application of salvarsan within the last few 
years. Salvarsan is nowadays employed with more or less efficacy 
for the treatment of the following diseases: spirochetosis, trypan- 
osomiasis, malaria, amoebic dysentery, leishmaniosis, bacterial 
diseases, diseases caused by unknown viri. 

i. Spirochetosis. We can here enumerate relapsing fever, fram- 
bcesia or yaws, Vincent's angina, avian spirochetosis, and rat-bite 
fever. These are, as a rule, cured by one injection of salvarsan. In 
these cases, salvarsan attains indeed its ultimate end of therapia 
sterilisans magna. Rat-bite fever is found chiefly in Japan, and it 
may also be found in China. The remarkable therapeutic value of 
salvarsan against this disease, together with the discovery of Spiro- 
chceta icterohcemorrhagice , led Futaki and Ishiwara to the discovery 
of the causative agent of the disease and also to successful experi- 
mental infection in animals. This is a curious example of the reversed 
order of investigation in the annals of medical science. 



MORNING ADDRESSES 253 

To hope for the same amazing curative efficacy of salvarsan in 
all the other forms of spirochetosis would be, it seems to me, too 
hasty. Syphilis is not so easily amenable to salvarsan at a certain 
stage and form of that illness. This seems to depend chiefly on 
differences of the biological nature of spirochetes and especially on 
the shelter, in which they may lie unhurt by the injected remedy. 
The local treatment, which Flexner lays stress on, bears a high rela- 
tive importance. The intralumbar application of salvarsanized 
serum in syphilis of the central nervous system, which has been 
introduced by Swift and Ellis of The Rockefeller Institute for Medi- 
cal Research, fulfills Flexner's requirement. From the results of the 
practical application of their method, gleaned from years of clinical 
experience, I have come to the conclusion that it often has far more 
remarkable efficacy in the treatment of the central nervous system 
involvements than has the intravenous administration of salvarsan 
alone. 

I deem it proper here to say a few words on some of the newly 
introduced mercury preparations. As you all know, asurol is one of 
the very convenient mercury preparations for practical purposes, 
for it may be comparatively harmlessly applied to human cases in 
large quantity and thus a larger quantity of mercury may be intro- 
duced into the human body than when it is given in any other form. 
More recently another derivative of asurol by the name of "nov- 
asurol," which is a double compound of the sodium salt of oxy- 
mercurichlorphenylacetic acid and diethyl malonyl urea, has been 
widely employed. There are still other forms of mercurial com- 
pounds. They are mercedan (HgNa-paranucleic acid), contraluesin 
(a compound of gold with mercury), cystinmercury, etc., which are 
used for experimental purposes. There is reason to hope that there 
will be improvement in mercurial compounds. 

Now to return: Arsenics have been contraindicated in putrid 
bronchitis, bronchiectasis, and gangrenous pneumonia, but recently 
salvarsan has been known to produce remarkable improvement in 
these pulmonary affections. Such improvement may be due to the 
spirocheticidal action of salvarsan, which acts against the sapro- 
phytic spirochetes that may be found in the putrid foci in the lungs. 
Here these saprophytic spirochetes may also play a certain part in 



254 PEKING UNION MEDICAL COLLEGE 

the acceleration of putrefaction. Since these pulmonary affections 
have been found amenable to salvarsan, there have been many re- 
ports regarding spirochetes in the respiratory system. 

Another form of spirochetosis, ulcus tropicum, which is known in 
South China by the name of Annam ulceration or Cochin sore, has 
been reported by many observers to have been successfully cured 
by salvarsan or its substitutes. 

It is very interesting to notice that the leptospira group, which 
biologically are closely allied to spirochetes, have a remarkable re- 
sistance against saponin, which is a strong spirochetolytic agent, 
and that their infection cannot be cured by salvarsan, the specific 
remedy for all other spirochetoses. I have tried various chemical 
preparations in the infection from Leptospira icterohcemorrhagice ■, 
but none of them have been found efficacious. 

2. Trypanosomiasis. It is a well known fact that salvarsan and its 
derivatives have some efficacy against all kinds of trypanosomiasis. 
Nowadays, arsenophenylglycin is no longer employed in sleeping 
sickness., but salvarsan or its substitutes are in vogue. In the last 
stages of the disease when there is involvement of the central nerv- 
ous system, local treatment is needed. Haendel Joetten of Gesund- 
heitsamt reported that a proprietary remedy, Bayer 205, prepared 
and offered for sale in Germany in 1920, was a strong trypanocidal 
agent. Mayer and Zeiss of the Hamburg Institute for Tropical Med- 
icine verified the efficacy of this remedy by their experiments. This 
preparation is said to be efficacious against all kinds of trypanosomes, 
except Trypanosoma lewisi and S cbizotrypanosoma cruzi. The results 
of its application to various kinds of experimental animals showed 
that the therapeutic indices vary between 1 :2o and 1 :4c Mayer 
even obtained the favorable figure 1 :i6o in Trypanosoma gambiense. 
Although this species of Trypanosoma in the infected mouse is 
relatively easily curable, the therapeutic indices of either salvarsan 
or silver antimonium arsaminol varied between 1 130 and 1 -.33, and 
they never reached the figures shown by Bayer 205. I myself have 
had no experience with Bayer 205, nor have I heard anything of its 
practical application. Should the above-mentioned results be ob- 
tained in the human cases or in trypanosomiasis of large animals, it 
would be indeed a remarkable achievement. 



MORNING ADDRESSES 255 

3. Malaria. Although salvarsan is efficacious in all forms of 
malaria, yet the sterilization involves only the schizonts, and not 
the gametocytes. Therefore, salvarsan cannot be said to be supe- 
rior to quinine. Salvarsan may, however, be employed in quinine- 
fast cases and also in a combination treatment with quinine, so that 
a more powerful effect may be obtained. 

4. Amoebic Dysentery. This is a disease widely distributed over 
the entire area of China. Salvarsan has been found sometimes to 
produce a very remarkable improvement in this form of disease, 
but in some cases it has been found entirely powerless. Whether or 
not this uncertainty of the efficacy is due to the differences in the 
developmental stages or of the strains of amcebge, is still to be 
learned. At any rate, salvarsan has given place to emetin in the 
treatment of amoebic dysentery. Emetin was first used by Rogers. 
Of all the alkaloids that are found in the ipecacuanha root, this one 
is the most efficacious, but investigators are still searching for a 
satisfactory form in which to employ it. In order to avoid the by- 
effects of emetin, emetin bismuth iodide has been prepared, which is 
considered to pass the stomach unchanged and be digested by the 
intestinal juice before its action is developed. Emetin acts not only 
on amoebae but, to a certain extent, on Paragonimus westermannii, 
or lung-fluke, and also on bilharziosis. There is much to be learned 
about this alkaloid. 

5. Leishmaniasis. The only kind of leishmaniosis that can be 
ameliorated more or less by salvarsan is Oriental sore. Although 
there is a report that deals with the successful treatment at the 
initial stage of espundia, it is not yet an established fact. 

There is no doubt about the efficacy of antimonium against all 
forms of leishmaniosis. It was formerly administered in the form of 
tartar emetic, either internally or locally. Better success has been 
attained, however, by the intravenous injection of tartar. If arse- 
nics have any ameliorating action against leishmaniosis, they are 
better given in combination with antimonium. The only difficulty 
met with in experimental study, is that leishmaniosis cannot be 
developed in animals, while on the other hand only with difficulty 
can antimonium be directly combined with the benzene nucleus. 
For the time being, there is only one way of investigation open to 



256 PEKING UNION MEDICAL COLLEGE 

us. That is practically to apply a compound of antimonium and 
salvarsan to human cases. I have been informed of the fact that 
French-made "luargol" has been effectively employed on human 
cases of espundia in Brazil. The drug is a compound of silver, anti- 
monium, and arsenic. If a chemical production having a stronger 
action than luargol should be discovered, more successful treatment 
of such forms of leishmaniosis as Oriental sore, kala azar, espundia, 
etc., may be expected. 

Bilharziosis, filariasis, and similar affections which have been 
considered to be ameliorated to a certain extent by arsenics and 
antimonium preparations, may be even better treated by the above 
mentioned compound. It has been well known that antimonium has 
certain ameliorating efficacy against trypanosomiasis and spiroche- 
tosis, and, therefore, it is earnestly hoped that advance will be made 
in the chemistry of antimonium. 

6. Bacterial Diseases. Of all the bacterial diseases, human anthrax 
is the only one known to have been cured by salvarsan. It was 
applied for the first time without any scientific basis. Its specific 
bactericidal property, however, was established afterwards by try- 
ing the sterilization test both in vitro and in vivo. It has been reported 
that salvarsan is also efficacious against horse glanders and swine 
erysipelas. Last year, Kolle obtained 1 14 to 1 -.5 therapeutic indices 
with a preparation obtained by combining sulphoxylate and car- 
bamide against swine erysipelas. It is, however, still to be learned 
whether or not such arsenic compounds have any practical thera- 
peutic efficacy. The sterilization of bacteria and the chemotherapy 
of bacterial diseases with other chemical preparations than arsenics 
will be dealt with in a subsequent paragraph. 

7. Diseases Caused by Unknown Viri. Disease of the breast in 
horses is cured by one injection of salvarsan. Salvarsan has also a 
certain degree of efficacy in scarlet fever and smallpox of man. But 
it seems not to be due to the antiparasitic action of the drug, which 
is the first requisite in chemotherapy. Nearly all of the human 
diseases that are caused by either unknown or invisible viri have not 
been perfectly reproduced in experimental animals, and therefore, 
a rapid progress in their chemotherapy cannot be expected. 

Hitherto I have been dealing chiefly with salvarsan or its substi- 



MORNING ADDRESSES 257 

tutes, the kinds of diseases that are amenable to their administra- 
tion, and some two or three other chemical compounds have been 
comparatively considered. I have also dealt with certain diseases 
which seem to have closely related chemoceptors. I will now con- 
sider the internal and local disinfection of bacterial infections. 

INTERNAL AND LOCAL DISINFECTION OF BACTERIAL INFECTIONS 

Specific remedies against certain diseases that have become 
known empirically, such as quinine against malaria, mercury 
against syphilis, and ipecacuanha against dysentery, all belong to 
the treatment of diseases of protozoal origin. Chemotherapy as 
founded by Ehrlich also deals chiefly with the treatment of try- 
panosomiasis and spirochetosis, while the attempt to attain the 
internal disinfection of bacterial agents by the use of some chemical 
preparations such as have been tried by Koch, Behring, and others, 
has turned out to be futile. These facts almost caused us to conclude 
that internal disinfection was impossible. But this impossibility has 
been surmounted by the discovery of Morgenroth that quinine 
effects internal disinfection in pneumococcal infection. Almost 
simultaneously with his discovery, there were reports both by the 
Japanese and German observers that salvarsan has curative efficacy 
against anthrax in man. Study on the chemotherapy of the diseases 
of a bacterial nature has thus been reviewed, and further study 
opened the way to the discovery of chemical preparations having a 
bactericidal property, for use in local disinfection. 

The artificial cultivation of a large number of protozoa is hardly 
ever attainable. The only way, therefore, to test the germicidal 
action of a new chemical substance against them in vitro is to apply 
it to living specimens and see the change in their motions under the 
microscope. By this method we may be able to see the effect of the 
chemical substance on the bodily constituents that might have a 
certain relation to motion, but its action against the chromatic 
substance that plays an important role in the proliferation may be 
known only in vivo. There are not a few cases in which a curious 
phenomenon is encountered, namely, that, although in vitro a given 
substance is powerless against certain germs, in vivo it exercises a 
remarkable parasiticidal action. Thus in the study of chemotherapy 

18 



258 PEKING UNION MEDICAL COLLEGE 

of protozoa, the value of the simple and cheap method of test in 
vitro is greatly limited. Bacteria, on the other hand, can be tested 
for the action of any chemical substances that may be supposed to 
have germicidal power by cultivating the bacteria after contact 
with the substances in question. Thus the in vitro test will hold a 
high place in the chemotherapeutic study of such bacteria. The 
principle of chemotherapy is the research on the chemoceptor of the 
parasite. With bacteria, the direct proof of the presence of the 
chemoceptor can be shown by the cultivation of drug-fast bacteria, 
and can be made in vitro without employing experimental animals. 

One of the most important points that should be known in the in 
vitro investigation of chemotherapy is the choice of media in which 
the chemical preparations will act. Common disinfectants such as 
sublimate and carbolic acid exercise their highest efficacy in saline, 
but in the presence of serum or other colloidal substances, their 
disinfectant property becomes remarkably weak. Those drugs that 
are efficacious in internal disinfection, act as effectively in serum as 
in saline. Secondly, there is another factor which is as necessary as 
the former, that is, the specific disinfecting power against certain 
species of pathogenic micro-organisms. Common disinfectant 
develops its disinfecting power universally over all the species of 
bacteria, but disinfectants that can be employed internally should 
possess an especially strong disinfecting power against a certain 
species of bacteria. Quinine has a very remarkable disinfecting 
power against pneumococcus both in vivo and in vitro, as salvar- 
san has against Bacillus anthracis. 

Some years ago, Ehrlich studied the specific disinfectants 
against bacteria in co-operation with Bechhold and by coupling 
phenol or cresol with a certain halogen, they obtained disinfectants 
having a remarkably strong power against certain species of bac- 
teria, for example, tetrabromorthocresol, which has a specifically 
strong bactericidal power against Bacillus diphtheria. They called 
this kind of drug a half-specific disinfectant. Later Bechhold cou- 
pled a halogen with naphthol and found that monochlornaphthol 
has a remarkably strong specific disinfecting power against Bacillus 
tuberculosis and tribromnaphthol against streptococci and Bacillus 
diphtheriae. Jacobs of The Rockefeller Institute substituted urotro- 



MORNING ADDRESSES 259 

pin or hexamethylenetetramine with benzyl or halogenacetyl deriva- 
tives and obtained a number of new compounds. He studied the 
relation between the constitution and the disinfecting power of 
these compounds against Bacillus typhosus, meningococcus, and 
gonococcus. As the results of his studies, he found that a number of 
his new preparations possessed an unusual bactericidal action, 
which was to be observed even in the presence of serum or colloidal 
substances. From his work it can also be seen, that the partial 
specific bactericidal action of the preparations has a certain relation 
to their constitution. Such fundamental biological work is most use- 
ful for the furtherance of chemotherapy, though it may not be 
directly applicable in practice. His work seems to have been sug- 
gested by Flexner's discovery that urotropin has a curative efficacy 
against poliomyelitis. In America, urotropin has been employed in 
the treatment of typhoid fever and Weil's disease for the purpose 
of internal disinfection. Here it should be noted, however, that 
Trendelenburg has found that urotropin develops disinfecting 
action by decomposing into formalin only in an acid medium. 

By reviewing all the chemotherapeutic work hitherto published, 
it would seem very probable that internal disinfection has been ob- 
tained only in those species of bacteria that have a tendency to 
develop septicemia, while, on the other hand, those that cause local 
infection are better treated by local disinfection with the specific 
disinfectant. The following drugs have been found more or less 
effective in the chemotherapy of bacterial infections: quinine and 
its derivatives, acridine dyes, triphenylmethane dyes. 

DRUGS EFFECTIVE IN THE CHEMOTHERAPY OF BACTERIAL INFECTIONS 

/. Quinine and Its Derivatives. This is the drug first to be men- 
tioned in the chemotherapy of bacterial diseases. It is now an almost 
established fact that hydroquinine and the hydrochloride of ethyl- 
hydrocuprein or optochin, is, as discovered by Morgenroth, a specific 
remedy for pneumococcal infection. Since this discovery, he has 
been studying further with quinine and found that iso-octylhydro- 
cuprein, or vuzin, and isoamylhydrocuprein, or eukupin, have both 
a remarkable disinfecting action. Of these three, optochin has far 
less carbon content and is best adapted for internal disinfection, 



26o PEKING UNION MEDICAL COLLEGE 

especially for pneumococcus. Eukupin, which has a higher carbon 
content, may also be employed for internal disinfection, but it is 
slightly better adapted for use as a deep reaching focal disinfectant. 
Vuzin, which has the highest carbon content, is best fitted for focal 
disinfection. The latter two seem to be more efficacious against 
streptococci and staphylococci than against pneumococci. The 
specific relation of the three above-mentioned quinine derivatives 
against cocci is not notable. The facts that are interesting to the 
investigators are that there seems to be a certain relation between 
the sizes of the molecules and the processes of the disinfection. 

There are not a few reports dealing with the successful treatment 
of influenza with these quinine derivatives. It seems highly probable 
that they should have acted against the mixed infection from 
pneumococcus and streptococcus. 

2. Acridine Dyes. The action of this group of dyes against try- 
panosomes has been studied minutely by Ehrlich. Among the rest, 
diamino-methyl-acridine-chloride has the most powerful trypanoci- 
dal action, from which fact it has been given the name of trypafla- 
vine. English investigators call it simply by the name of acriflavine. 
Lately, Neufeld of the Koch Institute tested the disinfecting power 
of this dye and found that it had a strong sterilizing power against 
pneumococcus and chicken cholera bacillus. Moreover, he found 
that diamino-acridine, which is known by the name of proflavine in 
English, and which has no methyl group in its molecule, is more 
powerful than acriflavine, which is provided with a methyl group. 
These two drugs have been found to develop a higher disinfecting 
action in the presence of serum than in saline. The fact that acri- 
flavine has a higher disinfection in serum is indeed a paradoxical 
phenomenon, which can be easily proved. This fact led Langer to 
carry on further with the studies of this drug and to prepare new 
chemical substances having more methyl groups than flavine. Of 
these, the chloride of 2-7-dimethyl-3-dimethylamino-6-amino-io- 
methyl-acridine, or shortly called flavicide, has the strongest bacteri- 
cidal power and its immediate bactericidal power against staphy- 
lococci is ten times as large as that of acriflavine, and against the 
diphtheria bacillus five times. The inhibitory power against the 
growth of staphylococcus that is exercised by flavicide is five times 



MORNING ADDRESSES 261 

that of acriflavine, and against diphtheria bacillus it is only twice as 
great. Flavicide does not increase its bactericidal power in serum as 
does acriflavine. Langer tries to explain the differences of these 
experimental results by the differences of the physical natures of the 
remedies as shown in solution. The difference is, in brief, that the 
substances having more of the methyl group have a weaker disper- 
siveness and therefore more immediate bactericidal power. On the 
other hand, those that are provided with less of the methyl group 
have a stronger dispersiveness and have therefore a weaker bacteri- 
cidal power. In serum, however, the dispersion is remarkably in- 
terrupted and the results are that a stronger bactericidal action 
develops. On this hypothesis Langer concludes that acriflavine is 
better fitted for internal disinfection, while flavicide answers better 
for local disinfection. He also tries to explain the above-mentioned 
relation between optochin and vuzin. 

The results of the further experimental investigation made by 
Neufeld show that acriflavine has a high internal disinfecting power 
against meningococci, pneumococci, streptococci, Bacillus anthra- 
cis, and Micrococcus melitensis. Acriflavine has since been used, as 
optochin is used, with some success in all forms of septicemia, and 
flavicide has been employed as a local disinfectant in eczema, 
furunculosis, abscesses, conjunctivitis, otitis, and wounds, and in 
the treatment of diphtheria carriers. 

The genuine local disinfectants, such as chlorine in the series from 
Dakin's solution to dichloramine-T in the treatment of wounds, and 
choleval in gonorrhea, and yatren in diphtheria carriers, stand out- 
side of the scope of chemotherapy, and I will mention only the dis- 
infection of the typhoid bacillus in the gall bladder of typhoid 
carriers. 

j. Triphenylmethane Dyes. In the chemotherapeutic treatment 
of the experimental cholecystitis in the rabbit these dyes have been 
carefully studied. But unfortunately there has as yet been discov- 
ered no drug that can be applied with success to the cases of human 
typhoid carriers. It was only last year that Uhlenhuth and his co- 
workers found by experiments with a large number of chemical 
substances that methyl violet and fuchsin have given the most fa- 
vorable results. These drugs, however, cause a comparatively severe 



262 PEKING UNION MEDICAL COLLEGE 

inflammatory reaction in the injected tissues, and therefore, it still 
remains problematical whether or not they may be given to human 
cases in sufficiently large doses without any ill-effects. 

CHEMOTHERAPY OF TUBERCULOSIS 

The chemotherapy of tuberculosis has been attempted by many 
investigators, but there has been as yet no satisfactory result. Since 
the iodide of methylene blue has been reported by Finkler and von 
Linden, a number of drugs for tuberculosis have been reported from 
time to time. Above all, metallic compounds have been most fre- 
quently the object of investigation, the compounds of copper and 
gold being considered most promising. Some of these are cyanocu- 
prol of Koga, gold potassium cyanide, and cantharidine-ethylene- 
diamine (aurocantan) of Bruck. Recently in Germany the sodium 
salt of ^>-amino-o-aurophenol carbonic acid, which is a preparation 
in which the irritative cantharidine has been excluded from the 
composition, has been reported to have a certain efficacy against 
tuberculosis. It is largely employed in practice by the name of 
"krysolgan." In France, cerium salts are being widely studied. All 
these chemical substances have developed a remarkable curative 
efficacy in surgical cases of tuberculosis, such as joint or bone, but 
in the internal infection, such as in the lungs and in the intestines, 
no one of them produces any satisfactory results. Metallic com- 
pounds and metallic colloids are also employed in the various forms 
of bacterial infection, such as pneumonia, influenza, and septicemia. 
In certain cases they have been proved to be very effective, but 
when we come to consider the mechanism of their action, we are not 
certain whether they are really antiparasitic in the sense of chemo- 
therapy, or whether their efficacy is merely the result of catalytic 
action. 

CHEMOTHERAPY OF LEPROSY 

It has long been known in India that chaulmoogra oil has a certain 
improving power against the symptoms of leprosy. In Hawaii, Goto 
employed it more than a score of years ago. Formerly it was admin- 
istered only per os, but lately it has been employed by hypodermic 
injection. Much has been learned about the nature of the acid of 
this oil, and the greater efficacy of the sodium salt of its fatty acid 



MORNING ADDRESSES 263 

has been reported by Muir and Rogers in India, Hollmann in 
Hawaii, and by the Philippine Health Service. Very recently Dean 
in Hawaii prepared an ethyl ester of this fatty acid, which has been 
employed in the practical treatment of human cases first by Holl- 
mann and second by McDonald. In 1920 it was reported that sev- 
enty-eight patients had been paroled as they were no longer a 
menace to public health and not one of them is thus far known to 
have had any sign of recurrence. The Kalihi Hospital is now known 
among the laymen by the name of Mount Happy. Rogers also re- 
ports that a comparatively good result has been obtained by the 
use of this ethyl ester. If these wonderful results should be proved 
by further observations, it would be an important step forward, 
even if the cure is wrought in only a limited number of cases. 

CHEMOTHERAPY OF MALIGNANT TUMORS 

Finally, I will deal very briefly with the chemotherapy of malig- 
nant tumors. All the diseases that are caused by infectious patho- 
genic micro-organisms are the results of infection by foreign cells 
other than the cellular elements of the host, and naturally they may 
have all their own specific chemoceptors, which are different from 
those of the body cells. The tumor cells, on the other hand, consist 
of changed autogenous cells, or in other words, they are the hostile 
brothers of the body cells. The chemoceptors that they have, 
therefore, are common to all, and it must naturally be very difficult 
to find the small differences in the chemoceptors of these two 
brother cells. But the brilliant work on eosin-selenium attained by 
Wassermann and the so-called tumorafHn substances (which are 
obtained by the combination of various kinds of metals by Neuberg 
and the use of choline as a chemical imitation of the action of Roent- 
gen rays originated by Werner and Scesci) afford us a promising 
view of the future of the chemotherapy of malignant tumors. These 
have so far been studied only on experimental animals, and the trial 
of them in human cases is a matter of the distant future. In this 
difficult realm of investigation there has been as yet nothing prac- 
tical, but this is also one of the interesting fields open to the explora- 
tion of the followers of chemotherapy. We have reason to hope for 
success. 



264 PEKING UNION MEDICAL COLLEGE 

Thus far I have, from the standpoint of the laboratory investi- 
gator, dealt with almost all the work that has been approached in 
the advance of chemotherapy during the last ten years, together 
with the problems that are now laid before the investigators. The 
furtherance of chemotherapy cannot, however, be attained without 
the co-operation of the chemist and the biologist, with untiring 
perseverance and financial support. The chemical substances that 
should prove efficacious, must then be handed to the clinicians. The 
attainment of final clinical success can be reached only by the hand 
of the clinicians, who must study the effect of the remedies with an 
all-pervading observation in a wide range of experience and with the 
closest attention. The course of disease and the nature of the causa- 
tive agents are complicated and perplexing; and the final goal may 
in some cases not be completely realized by "therapia sterilisans 
magna." In that case we must be satisfied with " therapia sterilisans 
fractionata," or even with the "combination treatment." Again, 
sometimes it .may be necessary to apply local treatment according 
to the situation of the foci. All these problems, the choice of methods 
of treatment, the size of dose or the avoidance of ill-effects from the 
drug, may require even more hard labor on the part of the clinicians 
than the originators of the drug used in its preparation. 

In his great consideration and of his own accord, Mr. Rockefeller 
has appropriated an enormous sum to enable the Rockefeller 
Foundation to perform works of humanity. As one of its activities, 
this splendid institution, the Peking Union Medical College, has 
been established, comprising a large hospital and splendid labora- 
tories with the latest equipment for the care of patients and for 
carrying on medical research. Here able medical scientists will be 
educated and here numerous brilliant achievements in medicine 
will be accomplished. On the occasion of the dedication of this 
College and Hospital, the Kitasato Institute for Infectious Diseases, 
which has a purpose similar to that of your institution, expresses the 
hope of fraternal co-operation for the progress of medicine. In the 
name of science, I thank Mr. Rockefeller, and present my cordial 
respects to all members of the staff of the Foundation. 



CLINICAL SECTIONS 



DEPARTMENT OF GENERAL MEDICINE 



SYPHILIS 
By 

H. JOCELYN SMYLY, M. D. 
DIAGNOSIS 

In dealing with syphilis, an early diagnosis is absolutely essential. The earlier 
the diagnosis, the better is the chance for cure. In primary cases, a darkfield ex- 
amination for the spirochetes should be made and treatment instituted at once if 
this is found to be positive. In the examination of cases of syphilis, secondary 
eruptions should be looked for and ruled out from other skin conditions. The en- 
largement of lymph glands, particularly the epi trochlears, is an important find- 
ing. Further general examination should also include the teeth and size of the 
aortic dullness. 

TREATMENT 

Pyorrhea alveolaris and gingivitis should be taken care of. Frequent brushing 
of the teeth is to be urged, especially when patients are receiving some form of 
mercury. A tooth powder containing potassium chlorate is very effective. Cases 
with dilated aorta should receive a preliminary course of mercury and potassium 
iodide before the intravenous injection of salvarsan, and this is then employed 
with great caution. 

The use of mercury, potassium iodide, and the arsenical preparations may be 
discussed here. The intramuscular injection of mercury, given in the form of mer- 
cury salicylate, is the most satisfactory method to employ. Potassium iodide is 
valuable in tertiary cases, as it hastens the absorption of scar and granulomatous 
tissues. In all cases of syphilis, the use of salvarsan should be urged. The dosage 
employed is usually 0.5 gram, given every seven days for a period of five or six 
weeks, mercury being given concurrently or subsequently. During the past year 
there were two cases of severe salvarsan dermatitis in the clinic in Peking, and so 
the dosage has been reduced to 0.3 gram, given in weekly injections for ten weeks. 

DURATION OF TREATMENT 

This is a very debatable matter, and one which is being constantly changed in 
the various clinics. The tendency, however, is always in the direction of extension 
of the period. For security it is possible that a minimum of a year's treatment for 
primary cases should be given. Our practice has been to give treatment in ten- 
week courses until the Wassermann reaction has become negative and all symp- 
toms have disappeared, and then to advise the patient to report for re-examina- 
tion every two or three months for two years. A negative Wassermann after 
treatment does not indicate a cure in tertiary cases, since we see it in cases with 
active symptoms, especially in cases of involvement of the nervous system. 

A case was shown of primary reinfection as evidence of ineffectiveness in the 
cure of syphilis. This case was treated here in 1916 for secondary syphilis. 

269 



SYMPOSIUM ON KALA AZAR 
Participants: 

Dr. Oswald H. Robertson 
Dr. Richard H. P. Sia 
Dr. Charles W. Young 
Dr. John H. Korns 

Dr. Robertson showed an early case of kala azar and pointed out that the 
clinical picture presented by this patient might easily be mistaken for chronic 
malaria. The different types of kala azar encountered were then briefly discussed. 
Special reference was made to certain cases in which marked enlargement of the 
spleen and liver may be present without anemia or febrile reaction. Two other 
cases, with cancrum oris (healing), were also shown. 

Dr. Sia read a paper on a simple diagnostic test for kala azar, and demon- 
strated its technique. The method employed consisted of adding 20 cmm. 
blood from skin puncture to 0.6 cc. of distilled water in a small test-tube. The 
mixture was thoroughly shaken and the reading made at the end of five or ten 
minutes. A positive test was shown by the turbidity of the mixture and the forma- 
tion of a white flocculent precipitate on standing. This test has been performed by 
Dr. Sia on eighty-six patients suffering from various diseases, including ten cases 
of anemia with hemoglobin ranging from 30 to 60 per cent. It was found that 
positive tests were obtained only in kala azar patients and that all the cases of 
kala azar (sixteen in number) gave a positive reaction. The cause of the turbidity 
was further shown not to be due to incomplete hemolysis of the red blood cor- 
puscles, as was believed by Ray, but to an abnormally high amount of globulin 
in the blood serum of kala azar patients. The term "globulin precipitation test 
for kala azar" was suggested by Dr. Sia to replace the so-called "hemolytic test" 
employed by Ray. 

Dr. Robertson discussed the anemia occurring in kala azar and pointed out 
that little has been done to determine the nature of the anemia, whether it is due 
to increased blood destruction or whether a depression of the bone marrow func- 
tion is at fault. Results of the work being undertaken on this subject by Dr. Sia 
(as yet incomplete) would indicate that the anemia is due to bone marrow de- 
pression. 

An investigation of the cause of the bleeding in those patients with hemorrhagic 
manifestations revealed the fact that while the coagulation time of the blood 
was essentially normal, there was a marked delay in the bleeding time which was 
associated with a diminished number of blood platelets. This observation has an 
important bearing on the performing of spleen puncture. In order to make this a 
safe procedure we believe that the bleeding time should be tested beforehand in 
all cases. If a marked delay in bleeding time is found, the patient should be trans- 
fused. This brings about a shortening of the bleeding time; and spleen puncture 
can be safely performed. 

The technique of testing bleeding time according to the method of Duke was 
demonstrated by Dr. Sia. Normal bleeding time with this method varies from 1 
to 3 minutes. 

270 



GENERAL MEDICINE 271 

Dr. Young reported on cultures of kala azar which he was making. He used 
Nicolle,Novy,McNeal medium with the addition of 0.2 per cent potassium hydro- 
gen phosphate (KJrlPOJ and adjusted to definite hydrogen ion concentrations. 
The results from several series of cultures indicated that the optimum hydrogen 
ion concentration for the initiation of growth of kala azar from the Leishman- 
Donovan bodies lies between pH 7.4 and 8.0. In obtaining cultures he used spleen 
puncture with a 20 cc. syringe containing 10 cc. of Locke's solution. By using media 
buffered with phosphate, Dr. Young thought he had obtained later flagellate and 
"postflagellate" forms, resembling Leishman-Donovan bodies. They seemed to be 
somewhat similar to the corresponding forms reported by Patton (1) for Her- 
petomonas muscce domestic^ from the gut of flies. Such forms have not been re- 
ported previously in vitro. Cultures have been made, using washed but uninactiv- 
ated red blood-cells of the horse, sheep, rabbit, and man in the medium. Only 
those containing rabbit cells grew. None of the tubes to which the sera of these 
four animals were added, showed growth. Inactivated cells and sera had not yet 
been tested. Dr. Young called attention to the success of Patton (2) and Knowles 
(3) in finding Leishman-Donovan bodies in the peripheral blood, especially that 
of Knowles after injecting adrenalin. The latter had succeeded only once in thirty- 
four attempts to make blood cultures where the blood smears had been positive. 
Dr. Young had not succeeded in getting any cultures from the general circulation. 

Dr. Robertson gave a summary of the cases treated in the clinic with antimo- 
ny compounds during the past year. Potassium and sodium antimony tartrate as 
well as the colloidal antimony trisulphide were used. It was stated at the outset 
that a fair estimate of the results of treatment could not be given on account of 
the difficulty encountered in inducing patients to continue treatment over a 
sufficient length of time. Of sixteen patients in whom treatment with antimony 
compounds was begun, only seven received a sufficient amount of the drug. Four 
of the seven showed complete disappearance of all evidence of the disease. Final 
observations were made two to nine months after treatment. In all these patients 
the disease had been present only a short time before treatment was begun. The 
remaining three all showed very marked improvement but still had enlarged 
spleens. These patients gave a history of splenomegaly for a year or more before 
coming to the hospital. It is possible that in certain patients with a long history 
of kala azar a moderate degree of permanent splenomegaly may persist after the 
disease is cured. 

Dr. Korns reported on the experimental work with the different antimony 
compounds in rabbits and showed that potassium and sodium antimony tartrate 
and colloidal antimony trisulphide were all toxic beyond a definite dosage. There 
was no evidence that the colloidal antimony trisulphide was less toxic than the 
other drugs that have been in use previously, namely, sodium and potassium an- 
timony tartrate. His experiments also showed that none of these antimony com- 
pounds can be given intramuscularly, because experimentally in every instance 
the injection was followed by the formation of sterile abscesses. 

In a series of rabbits injected with antimony in these three forms over a period 
of four months, with a dosage equivalent to twice the maximum dose for a human 
being in proportion to the weight, all rabbits gained in weight. At autopsy one 
rabbit which had been given the potassium salt showed fatty changes in the liver, 



272 PEKING UNION MEDICAL COLLEGE 

but none of the others showed departure from the normal. It would seem from 
these findings that the human dosage, in the case of the sodium salt and the col- 
loidal sulphide, might safely be increased by from 50 to 100 per cent. 

Dr. Robertson spoke on the general treatment of kala azar, stating that blood 
transfusion had been found to be of much value in severe cases. In this hospital 
it has now become an essential part of the routine treatment in those cases with 
marked anemia. Two hundred to 300 cc. of blood is transfused in children, and 
400 to 500 cc. in adults. For cancrum oris the practice has been to curette where 
there is a large amount of slough, then to apply 50 per cent silver nitrate locally. 
This has given good results in several cases. There were two cases out of a series 
of eighteen that developed an edema of the larynx and had to be intubated. In 
both these cases it was necessary to keep the tube in place for several weeks. 
They both made a good recovery. 

Observations are being made on the effect of diet on recovery from the anemia 
of kala azar. This is based on the experimental work of Whipple and his co-work- 
ers, who found that dogs made anemic by bleeding and then kept on a purely 
carbohydrate diet showed a very slow blood regeneration or often none at all; 
whereas if such anemic dogs were put on a diet consisting largely of meat, recov- 
ery took place rapidly. Cooked liver was even more effective than meat. We are 
now adding to the diet of all kala azar patients a liberal amount of cooked liver. 
Recovery from the anemia of kala azar is a very slow process, hence any decidedly 
favorable effect which this diet may exert should become easily apparent. 

BIBLIOGRAPHY 

1. Patton, W. S., Lancet, 1909, i, 306. 

2. Patton, W. S., Indian J. M. Research, 1914-15, ii, 492. 

3. Knowles, R., Indian J. M. Research, 1920, viii, 140. 







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ELECTROCARDIOGRAPHY 

Dr. Franklin C. McLean demonstrated the electrocardiograph, including 
the taking of tracings. 

The three leads and their significance were briefly discussed. The main points 
emphasized were : (a) that the electrocardiograph shows the mechanism of each 
heart beat; {b) that it is through the studies in electrocardiography that recogni- 
tion of the arythmias was made possible, although the usual arythmias can now 
be diagnosed clinically without the use of the electrocardiograph. 

A series of slides was then shown, comprising the main abnormalities found in 
clinical work. 

Slide i. Normal electrocardiogram showing the normal auricular and ven- 
tricular complexes. 

Slides 2 and J. Auricular extrasystoles. Normally, impulse in the auricle arises 
from the sino-auricular node, but in abnormal cases the impulse may arise from 
any abnormal focus in the auricle, producing the condition known as auricular 
extrasystoles. 

In this connection it is to be noted that the premature auricular contraction is 
followed by a normal ventricular response, and this by a long pause. 

Slide 4. Nodal rhythm. 

Slide 5. Tachycardia. Rapid but normal auricular and ventricular complexes. 

Slide 6. Ventricular extrasystoles. This is most common among the premature 
contractions. There is a premature contraction arising in the ventricle and fol- 
lowed by a compensatory pause. 

Slide 7. Paroxysm of ventricular tachycardia. 

Slide 8. Sinus irregularity. This is normal in dogs and is of little clinical im- 
portance in man. 

Slide g. Sino-auricular block. In this condition the impulse from the sinus fails 
to reach the auricle. 

Slide 10. Incomplete auriculo-ventricular block. Occasionally auricular beats 
fail to produce ventricular response. Atropin usually restores the normal rhythm 
in this condition. 

Slide 11. Complete auriculo-ventricular dissociation: auricle and ventricle con- 
tracting independently of each other. There is no time relationship between the 
auricular and ventricular complexes. 

Slide 12. Prolonged conduction time. 

Slide 13. Auricular fibrillation. Most common. There is a continuous fibrillation 
of the muscular fibers of the auricle, each contracts independently of the other. 

This condition once established usually lasts throughout life, except for the 
transitory forms often observed in cases of acute lobar pneumonia. It is in auric- 
ular fibrillation that digitalis does the most good. Recent reports of German in- 
vestigators have given good results with the use of quinidine, normal rhythm 
being restored by its use. This drug is, however, still in the experimental stage. 

Slide 14. Auricular flutter. Extremely rapid auricular contractions with va- 
rious grades of heart block. With the administration of digitalis, it may pass on to 
fibrillation, then the restoration of normal rhythm takes place when digitalis is 
stopped. 

Slide 15. Mitral stenosis. 

19 2 73 



CONFERENCE ON LEPROSY 

Participants: 

Dr. Victor G. Heiser 
Miss Ruth A. Wood 
Dr. R. M. Wilson 

Dr. Heiser gave a brief resume of the use of chaulmoogra oil in the treatment 
of leprosy. This oil has been used by mouth for many years by natives of the 
countries where the oil is produced, and has always been supposed to have cura- 
tive properties. On account of the fact that few individuals can tolerate the oil by 
mouth for a sufficiently long time to produce a cure, its use was not very effective, 
until other methods of administration were tried. While in the Philippines, Dr. 
Heiser developed a formula for administering the oil intramuscularly, and was 
able to produce beneficial results in a considerable proportion of cases. At his 
suggestion the problem of isolating and purifying the active principles of the oil 
was taken up by Sir Leonard Rogers, who prepared the sodium salts and the 
ethyl esters of the fatty acids of chaulmoogra oil, and found that the therapeutic 
results were improved and the toxicity and unpleasant effects of administration 
were lessened. This work is being continued by Sir Leonard Rogers and by Dr. 
A. L. Dean of Honolulu who has improved the method of preparation of the ethyl 
esters and is also preparing other derivatives of the oil. Dr. Heiser has recently 
had an opportunity of observing the results of treatment with the newer prepa- 
rations, and he estimates that about 50 per cent of cases of leprosy can be cured 
by the methods now available. Dr. Heiser questions the wisdom of spending 
large sums of money for isolating lepers and believes that better results will be 
obtained by spending the money on the treatment of cases in hospitals or in the 
homes of the patients. There are about six thousand cases of leprosy in the Philip- 
pines, all on one island, and the Bureau of Science is preparing to manufacture 
the ethyl esters of chaulmoogra oil in large quantities for the treatment of all 
cases. 

Miss Wood, formerly a chemist in Dr. Dean's laboratory in Honolulu, and now 
in the chemical laboratory of the Department of Medicine of the Peking Union 
Medical College, gave a brief description of the chemistry of chaulmoogra and 
other oils used in the treatment of leprosy. She described the process by which Dr. 
Dean prepares the ethyl esters of chaulmoogra oil, and gave some indication of the 
direction in which his present researches are leading him. 

Dr. Wilson, of the Kwangju Leper Home, Kwangju, Korea, described the re- 
sults obtained by him in the treatment of leprosy by the Heiser formula, slightly 
modified (1 per cent of camphor in chaulmoogra oil). Dr. Wilson gives about 6 cc. 
of this mixture intramuscularly once a week, until cure is effected. He believes 
that the treatment will be improved by the use of the ethyl esters, but he has had 
such encouraging results with the present method that he believes it should be 
used until the newer method becomes more generally available. 

Dr. Wilson discussed the sources of the oil. He obtains it from Japanese sources 
Chobei Takeda, Doshomachi, Kobe, Japan) at about two yen per pound. This 

274 



GENERAL MEDICINE 275 

oil is likely to be adulterated, but has given good results in his hands. He also 
obtained oil from Calcutta (Smith Stanistreet). 

There followed a general discussion of the leprosy problem, in which the fol- 
lowing points were brought out: 

I. There are probably about five hundred thousand lepers in China. 

1. For the great majority of these cases, no treatment is at present available. 

3. Ethyl esters of chaulmoogra oil are at present either unobtainable, or are too 
expensive for general use when obtained from commercial sources. 

4. Until ethyl esters are obtainable, the chaulmoogra oil itself should be used 
for treatment, 4 to 6 cc. of chaulmoogra oil with 1 per cent camphor should be 
given intramuscularly weekly. 

5. Dr. Heiser will endeavor to learn whether the Philippine government will 
supply the ethyl esters to physicians in China at cost price, and this information 
will be given out by the Department of Medicine of the Peking Union Medical 
College. 

6. The Peking Union Medical College can be of service to physicians in China 
in the following ways: (a) by disseminating information as to the value of prep- 
arations, as to sources of supply of chaulmoogra oil and its derivatives, as to 
methods to be employed in the treatment of leprosy; {b) by investigating methods 
for the detection of adulterants of chaulmoogra oil; (c) by investigating the pos- 
sibility of substituting other oils, native to China, for chaulmoogra oil in the 
treatment of leprosy. 



CONFERENCE ON SPRUE 

Participants: 

Dr. H. Jocelyn Smyly 
Dr. J. B. Grant 
Dr. E. W. Ewers 
Dr. Ralph G. Mills 
Dr. R. M. Wilson 
Dr. Samuel Cochran 

Dr. Grant reported first hand observation of the work of Dr. Bailey K. Ash- 
ford in Porto Rico. Ashford in 1914 claimed to have isolated from tongue scrap- 
ings and stools of sprue cases an organism which he thought to be the causative 
agent of sprue. This organism was also found in mouldy bread. With his associates, 
Ashford developed a vaccine treatment, which they first claimed to be curative in 
100 per cent of cases. Dr. Grant observed one of their cases during treatment over 
a period of six months. This was a severe case, treated with an autogenous vaccine. 
After a month of weekly injections the sprue stools cleared up, but the stools did 
not become normal. There was no further improvement after three months more 
of treatment and Ashford finally gave up this case. In every patient seen by Dr. 
Grant the results were the same, the sprue stools cleared up, but there was not 
complete cure. 

Dr. Grant's opinion is that sprue is due to dietary deficiency with a secondary 
infection. He does not believe that Ashford's vaccine will cure sprue, although it 
is of benefit in clearing up the stools. Dr. Grant referred to an article by Dr. 
Trevor B. Heaton (1) in which the conclusion is reached that sprue is due to a 
physiological deficiency of ferments. 

Dr. Ewers stated that sprue is common in all parts of China. In South China he 
said most cases are in pregnant foreign women, in Central China in single foreign 
women, most of whom were on their second term in China. He has seen only one 
case in a Chinese, working in a foreign drug store. He has seen no cases cured. Fat- 
free milk, given in quantities of about 5 liters a day will quickly stop the intesti- 
nal symptoms, but will not cure the disease. Dr. Ewers stated that some of the 
common symptoms, in addition to the tongue and gastro-intestinal symptoms, 
are changes in disposition of the patient, increasing irritability, shortening of 
memory, and tetany. In the terminal stages the liver is very small, there is an ad- 
vanced degree of emaciation, and the skin is yellow. 

Dr. Ewers said that he had heard recently from Dr. Ashford, who now sus- 
pects that the pancreas is at the root of the condition, and that Dr. Ashford is 
now giving 1 gram of pancreatin with every feeding. 

Dr. Mills described an autopsy on a case of sprue, in which he found extreme 
emaciation and atrophy of the mucosa of the intestines. The pancreas was small 
but no structural changes were found. 

Dr. Wilson stated that there are about twenty-five cases of sprue in Korea, 
among about seventy-five missionaries. Dr. Wilson believes that the tongue symp- 
toms, and gas and pain in the abdomen are early symptoms, and that diarrhoea 

276 



GENERAL MEDICINE 277 

comes later. He has seen no cases in Koreans. He has used buttermilk with benefit, 
and advised giving fruit. 

Dr. Cochran suggested that the etiology is from bread made with contami- 
nated yeast cultures, and suggested that particular attention be paid to this. He 
stated that soy-bean products are valuable in the diet. 

DISCUSSION 

There followed a general discussion in which the following points were brought 
out: 

1. Sprue is common among foreigners residing in China and Korea, especially 
among missionaries, but either does not occur, or is very rare, among Chinese and 
Koreans. It is more common among foreigners who have resided for a long time in 
the Orient, and has not been observed in individuals who have lived in China for 
less than one year. 

1. It is either incurable, with present methods, or practically so, and runs a 
chronic course of long duration, usually terminating fatally. 

3. The vaccine treatment of Ashford and his collaborators is of some benefit, 
but is not curative. 

4. An exclusively milk diet, preferably of fat-free milk, is of the greatest benefit 
in alleviating the symptoms. Buttermilk, soy-bean products, and fruit are of 
value in the diet. 

5. Medication, with the exception of alkalis, which help the tongue symptoms, 
is of no value. 

6. Cases are as a rule better treated on the field, where the medical profession 
is experienced in the treatment of the disease, than by sending them back to 
America or England. 

7. Studies of diet in relation to the cause of the disease, of pancreatic func- 
tion, and of contamination of food supplies, particularly of bread, are most likely 
to give information of benefit in combating the spread of the disease. 

BIBLIOGRAPHY 

1. Heaton, T. B., Indian J. M. Research, 1920, vii, 810. 



TUBERCULOSIS 

By 

John H. Korns, M. D. 

A. PROPHYLAXIS 

/. Source of Infection 

Because of its bearing on prophylaxis we are interested here in China in the 
incidence of infection of man with the bovine type of the tubercle bacillus. Does 
this type of infection occur in China? According to Kitasato it does not occur in 
Japan, and conditions are similar here in China. That is, cows' milk is little used, 
beef is little eaten. I am anxious that those of you in North China who are re- 
moving tuberculous glands from children under fourteen years of age, send me 
the fresh glands for injection. The rabbit I pass around, which was autopsied this 
morning, was injected intravenously July 11 with 0.01 mg. of virulent bovine 
tubercle bacilli. After running a febrile temperature and losing 450 grams weight, 
it has succumbed. You see the lungs are studded throughout with small yellowish 
nodular masses; the liver and kidneys also show tubercles. These areas under the 
microscope show numerous tubercle bacilli. 

On the same date (July 11) another rabbit was similarly injected with human 
tubercle bacilli. This rabbit has gained in weight and is afebrile. 

This illustrates the relatively greater susceptibility of the rabbit to the bovine 
strain, and establishes, therefore, one means of differentiation. 

Besides cattle as a possible source of bovine infection in China, we must think 
of hogs. Hogs are numerous, are in rather close contact — if not directly, at least 
through their excreta and through flies — with the food of children in China. We 
are ignorant of the incidence of swine tuberculosis in China, but if it in any degree 
approaches the incidence in the United States, this factor must be considered. 

The estimate of Rogers, based on packing house inspections, is that there are 
ten million tuberculous hogs in the United States. In China, however, the greatest 
menace is the open human cases of pulmonary tuberculosis. I think we are safe in 
assuming this; and while we may be unable in our clinics materially to affect ad- 
vanced open tuberculosis, yet if we can make patients thus affected harmless to 
the community by properly caring for their sputum we are doing a good work. 
Supposing one patient expectorates twenty billion organisms a day, it is extreme- 
ly important that this source of infection be eliminated. 

2. Childhood Infection and Reinfection 
You are familiar no doubt with figures collected in other countries with regard 
to the high incidence of childhood infection. Hamburger, in Vienna, showed that 
by the time the fourteenth year of age has been reached 94 per cent respond posi- 
tively to the von Pirquet test. In New York, Park found at this age 75 per cent. 
It is altogether likely that in China, a highly " tubercularized " nation, a similar 
high incidence occurs. Now if children are practically all infected, is there danger 
later in life from reinfection? Is it sufficient for us to direct all our prophylactic 
measures toward protecting children? 

278 



GENERAL MEDICINE 279 

On examining the literature one finds that there are diverse views with regard 
to the possibility and common occurrence of reinfection. Bushnell (1) says rein- 
fection cannot occur after a preliminary infection has been established. A patient 
with pulmonary tuberculosis will preserve his immunity to the end of his life. 
Cornet, von Behring, Hamburger, and Romer adhere to similar views. 

Adami (2) holds that the relative rarity of the bovine type in adults demands 
one of three views: 

1. That the bovine infection acquired in childhood is peculiarly fatal so that 
all persons affected die in their early years (and this has no support in fact); 

1. That in many cases it dies out and is replaced later by infection with the 
human type (and there is no clear proof of this); 

3. That gradually through long residence in a human host the bovine form 
takes on the character of the human strain. The fact that we occasionally find 
intermediate strains seems to favor this third view. But some would say in reply 
to the third alternative that these so-called intermediate strains are really mixed 
cultures, containing both human and bovine strains. 

On the opposite side of the fence are men like Theobald Smith who thinks the 
tubercle bacillus coming to the lungs from without has as good a chance as one 
carried there from a pre-existing focus. Smith has shown in experimental work 
that it is the size of the reinfecting dose which is important. 

Krause thinks reinfection possible, hence the importance of environment. 

Calmette believes reinfection occurs, the adult consumptive being one who has 
received since childhood successive more or less massive reinfections. 

In the face of these views upholding the possibility of reinfection, as well as in 
the face of our own clinical experience, we are not justified, therefore, in limiting 
our prophylactic work to children. Nevertheless, we in China should stress efforts 
to protect children from repeated massive infections, separate babies from tuber- 
culous mothers and amahs, and teach the means of transmission of the disease 
most likely and most preventable in the homes. 

B. EARLY DIAGNOSIS 

One of the most discouraging features of tuberculosis work in China is the 
enormous percentage of advanced cases which come for treatment. Those of you 
who in mission stations or elsewhere act in the capacity of health officers do, 
however, have the opportunity to detect early cases and should be prepared to do 
it. We are struck with the large numbers of students of the asthenic type, and I 
want Dr. Willner, who is in charge of student and staff health here, to speak 
briefly about his observations and measurements. (Dr. Willner described the 
Becker-Lennhoff index and Koranyi's sign.) 

Those of you who have access to the Roentgen rays will agree with me that 
this method of diagnosis is of great value in many early cases showing no physical 
signs or only equivocal ones. (Four cases were shown to illustrate the value of the 
X-ray both in detecting early tuberculosis of the lungs and in following the 
course of the disease. Films taken at six-month or nine-month intervals were also 
demonstrated. In connection with one, a case of hilus tuberculosis, the value of 
D'Espine's sign was emphasized.) 

Some of you are so situated that you cannot use the X-ray in routine work. 



280 PEKING UNION MEDICAL COLLEGE 

You will agree that if we had some specific test for active tuberculosis that is 
simple in its technique and interpretation all of us would be greatly delighted. In 
1919 Wildbolz described his auto-urine test which he claimed was specific. This 
has been confirmed by Imhof, Gramen, and Alexander. One of the best discus- 
sions I have seen, together with confirmatory tests, is by Gibson and Carroll (3). 
(The theory and technique of this test are described.) 

While our own experience is too brief to be certain of the specificity and value 
of this test, the results of others suggest it to be of distinct use. 

C. CHEMOTHERAPY 

Our conference on the treatment of leprosy day before yesterday was valuable 
and showed that rapid progress has been made recently. Are we too sanguine in 
expecting similar progress in the treatment of tuberculosis? I had expected Dr. 
Shiga to talk on the chemical treatment of tuberculosis, but he was obliged to 
leave the city this morning. The literature on this subject is extensive and in the 
time remaining I shall touch only upon the work initiated by Sir Leonard Rogers 
and carried on by his colleagues in India. Rogers thought he had found sodium 
morrhuate to be helpful in leprosy and so was led to conclude that there is noth- 
ing specific against the leprosy bacillus in the chaulmoogra oil series. Naturally, 
it occurred to him that in tuberculosis, another disease caused by an acid-fast 
bacillus, the fatty acids of these oils might be efficacious. First reports upon the 
use of sodium morrhuate in tuberculosis were very encouraging. 

Other workers in the United States have had negative results, and now Rogers 
(4) himself confesses that neither the morrhuates nor the chaulmoogrates have 
been able to influence the course of tuberculosis in rabbits and goats. Walker and 
Sweeney showed both to be bactericidal to the tubercle bacillus in vitro. Here 
again we see the danger of drawing too many inferences from successful test-tube 
experiments. 

BIBLIOGRAPHY 

1. Bushnell, G. E., A study of the epidemiology of tuberculosis, New York, 1920. 
1. Adami, J. G., Medical contributions in the study of evolution, London, 1918. 

3. Gibson, C. B., and Carroll, W. E., J. Am. M. Assn., 1921, lxxvi, 1381. 

4. Rogers, L., Practitioner, 1921, cvii, 77. 



DEPARTMENT OF GENERAL SURGERY 



OPERATIVE CLINIC: RADICAL CURE OF INGUINAL HERNIA 

By 

Adrian S. Taylor, M. D. 

The operative procedure was as follows: The skin was prepared by painting 
with 5 per cent tincture of iodine. An oblique incision was made above Poupart's 
ligament, beginning above i cm. medial to the anterior superior spine of the ilium 
and ending i cm. lateral to the pubic spine below. The aponeurosis was split, the 
superficial ring opened, and the aponeurosis reflected upward to the edge of the 
rectus and downward to Poupart's ligament. The cremaster muscle and fascia 
were divided longitudially along the cord, and the sac at once opened. With the 
finger within the sac, it was separated from the cord by sharp dissection. Its neck 
was isolated, and after inspection of its interior it was twisted and the neck trans- 
fixed at its highest point and tied with medium silk. The sac was then cut off, and 
the stump was seen to retract well beneath the internal oblique. 

Without disturbing the cord, closure was done as follows. The cremaster muscle 
was draw in under the internal oblique and sutured up under this muscle with 
mattress sutures of fine silk. The edge of the internal oblique, with the conjoined 
tendon, was sutured to Poupart's ligament. Interrupted sutures of medium silk 
were used. The cut edges of the aponeurosis were overlapped and sutured with 
silk. Scarpa's fascia and the skin were closed separately with interrupted sutures 
of fine silk. A dry gauze dressing was applied. 

In the course of the operation, Dr. Taylor made the following remarks: The 
anterior superior spine of the ilium and the spine of the pubis are first identified, 
and the incision made through the skin, beginning above, medial to the first and 
ending below, lateral to the second. The aponeurosis is first opened above the ring 
and the incision carried down into the ring. Here one sees the ilio-hypogastric and 
the ilio-inguinal nerves lying beneath the aponeurosis. They are to be protected 
from injury. The cremaster muscle in this child is not well developed; it is incised 
along the cord and the large sac, which we see here, is opened. We were sure from 
our examination before operation that this was not a congenital hernia. This is 
verified by the ease with which the sac is separated from the cord. Now we have 
exposed the vas. This must be preserved, and here we may use a little gauze dis- 
section, although we greatly prefer the sharp scalpel to rubbing with gauze. The 
sac is now free, and we isolate its neck above. Here the cord leaves the sac, and 
isolation of the neck is usually very easy. There is little danger of injury to the 
bladder in cases of this kind, while in direct hernia there is great danger in cutting 
or transfixing tissue lying outside the sac about its neck. We now inspect the in- 
terior of the sac and while watching the neck inside, we gently twist. It is now 
transfixed with fine silk, and as the assistant relaxes by untwisting, the neck is 
tied. The interior is again inspected, and being empty, the sac is cut off close to 
the suture. The stump is now allowed to retract, as you see, beneath the edge of 
the internal oblique muscle. 

The first step in the repair was suggested by Dr. W. S. Halsted of Baltimore 
many years ago. I have here the cremaster muscle, which I will draw under the 

283 



284 PEKING UNION MEDICAL COLLEGE 

edge of the internal oblique muscle in this way. You notice that I place the fine 
silk mattress sutures through the internal oblique well up on the face of the muscle. 
These sutures will catch the edge of the cremaster and draw it up beneath the 
internal oblique. As I tie these sutures, you notice how they roll out and make 
very prominent the edge of the internal oblique. These sutures also relax the 
muscle and bring its lower edge closer to Poupart's ligament, and undoubtedly 
relieve the tension on the sutures to be placed next. 

The edge of the muscle and conjoined tendon is now approximated to Poupart's 
ligament with interrupted silk sutures. You notice how I place the lowest suture, 
attempting to include a bit of Gimbernat's ligament. This suture when tied ap- 
proximates the structures closely about the cord at the pubic spine. There is 
little danger of constriction of the cord here. The lower cut edge of the aponeuro- 
sis is now to be drawn up on the internal oblique and sutured in place. The upper 
edge is drawn down over the lower and overlapped. All vessels will now be tied 
with fine silk. The wound is now perfectly dry. We feel that complete hemostasis 
is very important, and we tie every bleeding point with fine silk. The edges of 
Scarpa's fascia are now brought together with fine silk, and the skin closed like- 
wise with interrupted sutures of fine silk. 

I consider silk far superior to catgut for this operation. We do not use large 
strands. The strain is evenly distributed over many interrupted sutures, carefully 
tied, and we believe that there is less cellular reaction about these sutures than 
about catgut. Infection in our hernia wounds almost never occurs, and we have 
had no experience with sinuses leading down to the silk sutures. After infection 
there is recurrence in 50 per cent of cases. In children, without infection, cure is 
certain in practically all cases. In patients of all ages with indirect hernias, one 
may expect recurrence in about 5 per cent. In direct hernias the percentage of 
recurrence will be very close to 20 per cent. 

A second case of the same condition was operated upon. The procedure and the 
surgeon's observations were the same as in the first case. 




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DEMONSTRATION: BALKAN FRAME AND APPARATUS FOR THE 
TREATMENT OF FRACTURES 

By 

George W. Van Gorder, M. D. 

From the casualties of the recent war, we have learned a great many lessons, 
and one of the most important of these, surgically speaking, has been derived 
from the treatment of fractures. Not only has our knowledge of bone repair and 
injured joint function been greatly increased, but remarkable improvement has 
been effected in the methods of handling fractures to insure the best end results. 
Progress in this latter direction was due largely to the introduction and invention 
of certain kinds of surgical apparatus and splints. 

In attributing the advance to the employment of new splints, I am aware of the 
fact that a splint per se is not fool-proof and may permit a hideous deformity un- 
less used properly. It is the proper use of each splint that I now wish to infer, when 
speaking of their relative values. We all appreciate that it is the human element, 
the directing and manipulating hand of the surgeon, his thoroughness and strict 
attention to minute details concerning the fracture that has the most to do with 
its final good result. 

But some splints and apparatus, we must agree, are more nearly fool-proof 
than others; some answer a greater number of requirements, some are more prac- 
tical and adaptable. We must have in a splint the combined qualities of simplici- 
ty, adaptability, and proper mechanical principle; and the splints I shall discuss 
this morning will be, I think, of this character. 

First in order of its importance I will mention the Thomas splint, which, al- 
though not a new device, was not, previous to the war, so keenly appreciated as 
it is now. After the introduction and universal use of this splint in the British 
Army for fractures of the femur it was estimated that the previous mortality re- 
sulting from these cases was reduced by more than one half. Certainly all surgeons 
who have used the Thomas splint properly must be impressed with its simplicity, 
adaptability, and effectiveness. In demonstrating its application and use this 
morning, I shall not discuss its general mechanical principles, which are known 
to all of you, but shall mention only a few points that are of practical value. 

The first one is this — no matter what the size of the Thomas ring, if applied 
to the leg it must not ascend above the tuberosity of the ischium, but must im- 
pinge there and press against the tuberosity, if effective heavy traction on the leg 
is desired. Especially is this true in adult patients, who cannot stand heavy 
counterpressure against the ramus of the pubis or the perineum. If the ring is 
made to fit a patient's leg precisely, then it will naturally rest against the tuberos- 
ity, but if taken from a stock supply, as is the usual case, it may be excessively 
large and then will have to be held in place by being suspended from an overhead 
frame as illustrated by the case before you. Just enough weight is placed in the 
shot bag as the other end of the pulley rope to keep the ring continually in ap- 
position with the posterior surface of the leg. Thus if the patient lifts his body in 
the middle, as, for example, in using a bed pan, the Thomas ring automatically 

285 



286 PEKING UNION MEDICAL COLLEGE 

rises with him and is consequently not permitted to override the tuberosity. This 
idea of suspending the ring from above the body was first introduced, I believe, by 
Major Pearson of Edmonton, England, and its employment by him and many 
others has been rewarded by splendid results in the treatment of fractures of the 
femur. Without observance of this precaution, one can go so far as to say that no 
adequate traction can be obtained with comfort, especially if the patient is kept in 
a level position, and the value of the Thomas splint is, therefore, tremendously 
handicapped and sometimes nullified. 

The second practical point I should like to mention is the employment of a 
subsidiary iron splint identical with the lower portion of the Thomas and attached 
to it by a movable joint at that point where the patient's knee joint rests. This 
is known as a knee flexion apparatus, because the lower leg resting upon it is thus 
allowed to move up and down, flexing the knee at the will of the patient, who 
controls the movements by means of a pulley rope, as seen here. In any cases of 
traction employed above the knee joint, as in the use of ice-tong calipers, this 
knee flexion apparatus can be applied and thus prevent the knee joint from be- 
coming stiffened from disuse. In all fractures of the femur where union has already 
begun to take place, this accessory splint can be of great help in restoring early 
function to the knee joint. This procedure also originated, I am informed, in the 
fracture femur clinic of Edmonton, England. 

Another idea that is often of value in the use of the Thomas splint is to bend it, 
not at the knee joint, but at the site of the fracture, in such a way as to produce a 
convex anterior curve at a point just below the bone fragments. This is especially 
important in supracondylar and midshaft fractures, where the tendency for the 
bone fragments to sag is ever present. By thus arching the splint at a point just 
above the knee joint or in the midthigh, according to the site of the break, the 
bone fragments are lifted up and maintained in a proper position until union can 
take place. 

For fresh fractures with much displacement, in addition to the ordinary force 
of traction, one can apply lateral pressure to the leg at any point by means of a 
so-called "femur pressure pad," which can be attached to the sidebars of the 
splint. Then by means of a turn-screw the pad can be driven against the leg as 
firmly as is necessary to correct the alinement, which is noted by successive bed- 
side X-ray pictures. 

The Thomas splint which you see applied here, the knee flexion apparatus, and 
the present pads were all made in China at a total cost of $3.00 Mex. 

For compound fractures of the lower leg just above the ankle joint, where skin 
traction is out of the question and where a Sinclair skate is not strong enough to 
maintain a reduction of the deformity, we find the stirrup the most useful ap- 
pliance in securing traction. It is simple to apply and, overriding the superior sur- 
face of the os calcis, as it should, does not produce an osteomyelitis as the Stein- 
man and Hawley pins may do when driven through the bone itself. 

In the treatment of fractures of the humerus, the two splints here demonstrated 
are of especial value. One of the straight arm Thomas splints with elbow flexion 
attachment is comfortable and effective for bedridden patients and its use has 
the advantage of preventing stiffness of the elbow, during the period of bone re- 
pair. 



GENERAL SURGERY 287 

The other splint is the Jones arm splint, used for patients who are able to walk 
about. It is extremely useful for compound fractures in that dressings can be 
readily done without disturbing the support of the fracture. 

The purpose of the conference this morning was more that of a demonstration 
of apparatus than a treatise on the subject of fractures. The various splints, 
braces, leg pillions, and artificial arms which you see are those which we have 
found to be the most useful and practical, and which are constantly employed in 
this hospital. 



SKIN GRAFTING — THIERSCH AND REVERDIN 

Participants: 

Dr. George Y. Char 
Dr. Adrian S. Taylor 

Notes on the demonstration and discussion follow : The use of Dakin's solution 
in infected wounds has greatly increased the scope of skin grafting. Granulations 
growing up firm and red with a minimum of exudate offer an excellent ground for 
the transplantation of either large or small grafts. 

The large Thiersch grafts may be taken from the anterior surface of the thigh, as 
large as a person's hand. The sides of the thigh are supported by sand bags. The 
skin is stretched between the edges of two boards pressed against it. The graft 
may be cut as long as desired and as wide as the thigh permits of flattening. 

Reverdin "pinch grafts" are very satisfactorily made under local anesthesia. 
This method was demonstrated by Dr. Char. The external cutaneous and ante- 
rior crural nerves are blocked with novocaine. The grafts are taken by picking up 
the skin with the point of a needle held in an artery clamp. The top of the little 
hillock thus formed is cut off. The grafts measure about 5 by 12 mm. and are 
then transferred to the new field and pressed firmly against the bare surface. 
Several hundred may thus be transplanted, leaving spaces of 5 mm. between the 
islands. The thigh is then dressed with vaseline gauze. The grafted area is al- 
lowed to dry for eight to ten hours and then a gauze compress soaked in Dakin's 
solution is applied and changed every two hours for four days. After that a Carrel 
tube may be used over the gauze and the gauze changed every twenty-four 
hours. 

An important point to be remembered is that after planting the graft the needle 
and artery clamp must be reboiled before being used again, in order to avoid con- 
taminating the thigh wound. 



288 



EPITHELIOMA 
By 

Frank Meleney, M. D. 

INTRODUCTION 

I should like to review with you this morning some of the recent literature on 
epithelioma and give a brief description of the various forms. Dr. Tuffier and Dr. 
Taylor will discuss the surgical aspects, with special reference to two cases we 
have recently had in the hospital, and then we will use the microscope to show 
the various features of epitheliomata which have been described in the recent 
literature. Almost all of the special characteristics of epithelioma are shown under 
the microscope this morning, — curiously enough, I think, because we have had 
only twenty-three cases in the past fifteen months. 

The nomenclature is gradually becoming more and more clarified, so that when 
an epithelioma is spoken of, it now means just one thing, — a malignant tumor of 
squamous epithelium, — leaving the term carcinoma for a malignant tumor of 
other forms of epithelium. In spite of the fact that at the present time we know 
very little about cancer, it is surprising, in looking over the literature, to find the 
authorities speaking with unanimity of the cause of cancer. Paine, director of the 
Cancer Research Institute in London, believes that cancer is not a specific dis- 
ease due to a special parasite, but that it is a disorderly growth of epithelium, due 
to chemica' or physical irritants, of which the toxins of bacteria are the most im- 
portant. Ewing, in his textbook on neoplastic diseases, in speaking of epithelioma, 
says that he believes that in almost every case the disease is due to chronic traum- 
atism. He says that it arises from normal epithelium after a period of overnutri- 
tion and overgrowth, during which the subepithelial tissues show some changes 
which make them less resistant to the down growth of epithelium. Those changes 
are lymphatic infiltration, mucoid or other forms of degeneration, atrophy of 
elastic tissue, fibrosis and chronic edema; and they usually, but not always, 
precede the down growth of epithelium. He says we must consider that normal 
epithelium has the power of becoming malignant if the proper conditions are 
brought about, but that there must be inherent in the epithelial cell itself some 
controlling influence which makes it grow outside of its normal limits. Broders 
and MacCarty, who are pathologists at the Mayo Clinic, believe that chronic 
degeneration of any specific tissue results in pathological, histological, and clini- 
cal changes in that tissue. The histological changes are hyperplasia, hypertrophy, 
and migration of the cells. The biological changes are hyperactivity and regenera- 
tion, and the clinical changes are either malignancy or benignancy. Broders, who 
has very extensively summarized the material from the Mayo Clinic, believes 
that cancer is not a degenerative process but a regenerative process; that the cells 
regenerate in response to an irritation; but that not only do they have the power 
of regeneration but also have the power of invasion and migration. Whereas the 
regenerative qualities are helpful to the normal body, the invasion and migration 
of these cells has a harmful effect. 

20 289 



290 



PEKING UNION MEDICAL COLLEGE 



It is interesting, I think, that these four authors who have written recently on 
epithelioma are so alike in their impression that irritation is the most striking 
cause. What evidence have we of the possible truth of this theory? There is no 
definite proof as yet, but the fact that epithelioma develops in the exposed parts 
of the body, the parts that are constantly exposed to irritation, and also that 
there are certain specific occupational forms, is significant. Chimney sweeps and 
paraffin workers develop epithelioma in the thigh. In Africa a form of epithelioma 
called kangri cancer appears on the abdomen, and it has been demonstrated that 
the natives there cause frequent irritation to the abdomen by holding a hot stove 
against it, for warmth or for some other purpose. It is well known that epithelioma 
develops on top of chronic ulcers, chronic osteomyelitis with sinuses, burns and 
scars, on X-ray burns, on lupus vulgaris, on pimples, on eczema, and other chronic 
lesions of the skin. This is the clinical evidence which we have that irritation is the 
cause of epithelioma. 

What statistical evidence have we? Broders, who has collected a large series of 
cases from the Mayo Clinic, has produced the figures shown in the following 
table, in his recent review of squamous-celled epithelioma of the skin, squamous- 
celled epithelioma of the lip, and basal-celled epithelioma. For our purposes I 
have combined some of the figures into a single brief table. (Table 1.) 

TABLE I 

Broderi Statistics 





Lip 


Skin 


Basal-Celled 


Male predominating . 


49-1 


4-1 


3- 2 


Farmers . . .... 


56 per cent 


53 per cent 


Predominate 


Average age . . 


57 years 


59 years 


56 . 7 years 


History of injury or irritation 


See below* 


24 per cent 


Irrelevant 


Following other lesions .... 


63 per cent 


51 " " 


37 per cent 


Average duration before being seen 


1 . 6 years 


4 . 8 years 


7 years 


Location above clavicle . . 


Lower lip, 96 per cent 
Upper ",3.5 " 


78 per cent 


96 per cent 


*Of cases of epithelioma of the lip 


80 per cent are smokers 






Of 500 normal individuals . . 


80 " " " 






Of epithelioma cases who are smok- 








ers . . 


78 use the pipe 






Of normal individuals who are 








smokers . 


38 " " " " " 







The table gives us statistical evidence of the effect of irritation or other lesion 
as an antecedent to the malignant growth. The figures in regard to pipe smoking 
are particularly interesting. In the skin epitheliomata 24 per cent were found to 
have a history of injury, and 51 per cent had some other form of lesion preceding 
the tumor. Inasmuch as, in the history, the diagnosis is made by the patient, it is 
difficult to be certain, of course, whether there was actually a different lesion or 
whether it was a form of the epithelioma which the patient did not recognize as 



GENERAL SURGERY 291 

such. In epitheliomata of the lip other forms of lesions, including ulcers, were 
found in 63 per cent. The same uncertainty holds here. In the basal-celled epitheli- 
omata a history of injury was irrelevant, but previous lesions were found to have 
been present in 37 per cent. 

We have, then, this clinical and statistical evidence that irritation may be the 
cause of epithelioma or cancer. It is obvious that this is much easier to demon- 
strate in epithelioma, which is a surface cancer, than it is in the deeper cancers, 
such as those of the breast, of the stomach, gall bladder, or liver. And it must be 
remembered that we have no real proof that irritation is the sole cause. 

Of the various classifications of epitheliomata that have been suggested, Bro- 
ders and MacCarty's is the most complete and satisfactory. They consider (1) 
squamous-celled epithelioma, (2) basal-celled epithelioma, (3 and 4) pigmented 
and non-pigmented melanotic epithelioma, (5) adamantinoma, and (6) a mixed 
type of squamous and cylindrical tumor. 

SQUAMOUS-CELLED EPITHELIOMA 

The squamous-celled epithelioma is found wherever squamous epithelium oc- 
curs in the body — in other words, all over the skin, the mucous membrane of the 
mouth, down the esophagus to the stomach, the mucous membrane of the penis, 
the vagina, the cervix of the uterus, and the anus. It is also found where transi- 
tional epithelium occurs and in certain other places where normal squamous 
epithelium does not exist — in the lungs, in the bronchi, in the trachea, and in the 
gall bladder, which have cuboidal or columnar epithelium. This fact brings out a 
question in regard to the origin of squamous-celled epithelioma. Does it come 
from the normal squamous epithelium or from embryonal cell rests, composed of 
cells which are destined to become squamous epithelium but which are misplaced? 
Some men consider one origin more likely and some another. Adami and Ewing be- 
lieve that normal squamous epithelium is always the source of surface squamous- 
celled epithelioma, and in those places where columnar epithelium is normally 
found it may actually change over into malignant squamous epithelium. Mac- 
Callum, on the other hand, suggests that those epitheliomata found in places 
where normally squamous epithelium does not occur arise from embryonal rests, 
which exist from the time the embryo is formed, and under certain conditions 
start to grow. This means that the rest must lie dormant for fifty or sixty years in 
some cases. On the other hand, there seems to be evidence that cylindrical epi- 
thelium can change into squamous epithelium. If there is complete inversion of 
the uterus, the exposed surface may develop squamous epithelium. The same is 
true if there is a complete prolapse of the rectum. So it may be also for the lungs, 
gall bladder, and other regions from some other form of irritation. 

Adami and McCrae say that serial sections have shown that a squamous-celled 
epithelioma may have more than one point of origin. Ewing believes that this 
and other cancers may have several foci of origin, which later fuse, and that as 
they grow they extend in part by the gradual transformation of previously nor- 
mal cells. MacCallum and others are of the opinion that malignancy begins at one 
point and spreads in all directions, pushing aside the normal epithelium but not 
actually changing the normal into the abnormal. Kilgore's recent study lends 
weight to this opinion. 



2 9 2 PEKING UNION MEDICAL COLLEGE 

Squamous-celled epithelioma may appear grossly in a number of different forms. 
It may appear as a papillary growth which is raised above the surface of the sur- 
rounding structures; it may appear as a cauliflower-like growth; it may be flat, 
and level with the skin, with simply a small raised margin, or it may be depressed 
and ulcerated. It may be soft or it may be indurated. 

The microscopic appearance of squamous-celled epithelioma is most interesting. 
We know that the normal epithelium of the skin is bounded by a very definite 
basement membrane. In the upper layer we have the keratinized dead cells, then 
the stratum lucidum, then the prickle cell layer, and at the deepest part the basal 
cells and the basement membrane. The basal cells are cuboid or columnar. They 
are dark-staining and have round nuclei, with very little cytoplasm. The cells of 
the prickle layer have a considerable amount of cytoplasm and tend to take a 
squamous form, and their nuclei are pale. The most striking change which occurs 
in squamous-celled epithelioma is that the basement membrane, which normally 
is very definite, is lost. It becomes indistinct or absent altogether. The epithelial 
cells seem to be tumbling down from the surface like water over a dam. They 
grow wildly without restraint. There may also be seen the changes in the subepi- 
thelial tissues which Ewing describes — lymphocytic infiltration, edema, mucoid 
degeneration, fibrosis. Secondly there is evidence of rapid growth. Mitotic figures 
are found — one in every three or four high power fields, or sometimes several in 
a single field. Thirdly the cells themselves become abnormal. Broders has brought 
out a very interesting point in this regard. He has divided squamous-celled epithe- 
liomata into groups, according to the degree of abnormality of the cell. He uses 
the terms "differentiated" and "undifferentiated." A differentiated cell is one 
which is like the normal adult squamous cell; the undifferentiated cell is supposed 
to have more primitive characteristics. It may look like a sarcoma cell; it may 
look like an embryonal cell. Let us consider this point for a moment. Kettle in his 
article on the polymorphism of the malignant epithelial cell says, "Everyone 
recognizes that the epithelial cell is capable of polymorphism, but without going 
so far as to say that the adult epithelial cell can actually become changed into a 
connective tissue cell, I am convinced that some carcinomata may possess such 
extreme power of polymorphic growth that their cells, losing all trace of their 
epithelial origin, may become indistinguishable from connective tissue elements. " 
The differentiated type tends to form pearls. A pearl is a group of squamous cells 
which have gone on to keratinization. Broders says that pearls and the cells im- 
mediately around them are not cancer cells because they have become adult 
squamous epithelial cells and have lost the power of growth. I believe, however, 
that his statement is misleading. I agree that those cells have lost their power of 
growth, because they are dead, but it is certain that they were once cancer cells. 
•If a pearl is found in a lymph node, for instance, one must say that the cells which 
formed it are cancer cells, because they had the power to leave the normal epithe- 
lium and invade the lymph node. Likewise if epithelium dips down into the deeper 
tissues as a malignant growth and later the cells go on their way to the adult form 
and become keratinized, a pearl is formed from cancer cells. 

The epithelial pearl is one of the striking features of squamous-celled epitheli- 
oma, but there are squamous-celled epitheliomata without pearl formation. In the 
less differentiated type of growth fewer pearls are formed. The cells do not grow to 



GENERAL SURGERY 



*93 



the point of keratinization. In the different grades of epithelioma we have all de- 
grees of differentiation, from the embryonal cell to the epithelial pearl. If there is 
complete differentiation the epithelium is normal. If the cells are one-fourth un- 
differentiated, Broders classifies the tumor in Group i. If there are equal portions 
of undifferentiated and differentiated cells he places it in Group 1. If three-fourths 
are undifferentiated he places it in Group 3. If all the cells are undifferentiated he 
classifies the tumor in Group 4. Broders claims that he can make a very definite 
prognosis from his grouping, quite independent of the clinical history and the age 
of the lesion. I believe that a more exact prognosis could be made if the age of the 
lesion were also considered. For instance, a Group 3 case developing in two months 
would be more rapidly fatal than one which had existed for two years. But this 
may be drawing too fine a point. 

The following table gives Broders' statistics, indicating the incidence and the 
mortality in the four different groups five years following the best operation that 
could be performed in the case. The mortality percentage indicates the prognosis. 
There is a striking similarity between the two types. (Table 2.) 



table 1 
Broders' Statistics 



Lip incidence . 
Deaths 

Skin incidence 
Deaths . 



Group 



per cent 

o 



Group 



per cent 
62 

55 
69 
61 



Group 3 



per cent 
21 
34 

17 

85 



Group 4 



per cent 
1 
100 

5 
100 



From these figures we may say that the more undifferentiated the cells are, 
the more malignant and the more fatal is the disease. A microscopic examination 
is obviously an invaluable aid to prognosis. I think that this classification should 
be followed up in more laboratories and hospitals, to see if these figures hold true 
elsewhere. This grading is the most significant work that has been done recently 
on epithelioma. 

Among other changes which occur is the appearance of what is called the one- 
eye cell. This cell has a large oval nucleus, with a single, very densely-staining 
nucleolus. Some tumors show many of these cells, others few. Their significance 
is not apparent. Also the mitotic figures are very frequently abnormal in appear- 
ance. They are distorted into bizarre shapes and have not the regularity of devel- 
opment which is normally seen in the mitotic figure. There may be three or four 
distorted mitotic figures in a single cell. 

What defense has the body against epithelioma ? There is often a lymphocytic 
barrier between the epithelium and the deeper tissue. There are also endothelial 
leucocytes, which occasionally fuse to form giant cells. Also fibrous tissue seems 
at times to block off the growth of the epithelioma. But that is all the body can do. 
The outcome seems to depend upon the virulence of the cell rather than upon 
the resistance of the individual. 



294 PEKING UNION MEDICAL COLLEGE 

BASAL-CELLED EPITHELIOMA 

The distribution of the basal-celled epithelioma is chiefly on the face. Ninety- 
six per cent of the cases are above the clavicle, and 90 per cent are above the line 
from the mouth to the mastoid. This is a very striking localization. Occasionally 
they appear in other parts of the body, in the deeper tissues and sometimes in the 
small intestine. 

Krompecher, in 1900, was the first to describe carefully this form of tumor, 
which he said came from the basal cells of the epithelium — the cells which line 
the basement membrane. The cells of a basal-celled epithelioma, for some reason 
or other, have not the power to become adult squamous epithelial cells; they can- 
not develop keratin; they do not form epithelial pearls; they remain small and 
round or polygonal and are dark-staining. Borrman believed that they do not 
come from the basement membrane but from embryonal rests. This theory has 
grown out of the fact that in some cases basal-celled epitheliomata are found 
which seem to have no relation whatsoever to the surface epithelium but lie en- 
tirely beneath it. Janeway believed that these epitheliomata might come from 
either embryonal rests or normal epithelium. Ribbert was of the opinion that 
they all come from normal basement epithelium. 

It is surprising that the basal-celled epitheliomata, which are composed of un- 
differentiated cells — young cells that have not the power to become adult cells — • 
are less malignant than the squamous-celled epitheliomata. This paradox has not 
so far been explained. Here we have undifferentiated cells but the tumor is very 
benign. It lasts a long time without killing the patient; it almost never metasta- 
sizes and it can be relatively easily cured. 

The gross appearance of the basal-celled epithelioma is often that of a nodule 
underneath the skin. It appears sometimes as a little sebaceous cyst or an adeno- 
ma; or it may appear as a persistent pimple; or as an ulcer which grows and does 
not show any tendency to heal, or tends to heal and then breaks out again; or it 
may appear as a scaly lesion with a coarse scabbing which forms and then rubs 
off. The basal-celled epithelioma spreads out laterally without penetrating very 
deep. It will go sometimes to the fascia and stop there. On section it may show a 
fairly definite limitation at the fascia. Or it may break through at one point and 
spread down to the muscle or bone and be checked there, and later break through 
the periosteum and get into the bone. When it occurs around the eye or nose or 
ear it may destroy large areas of the face and get into the sinuses. 

Let us consider the microscopic appearance. The cells appear as small, dark- 
staining round cells, which do not show prickles; and although they may show 
enormous numbers of mitotic figures and grow very rapidly, the tumor is rela- 
tively benign. Instead of forming epithelial pearls the center of a cell mass will 
often show simply cellular debris. Sometimes these cell masses contain cyst-like 
cavities, and the tumors have often been diagnosed as alveolar sarcoma or 
endothelioma. 

Going on to the other forms, I will run over them very briefly, because although 
they are important, they are relatively infrequent. 

MELANOEPITHELIOMA 

The origin of this type of growth is supposed to be the mole cell which lies im- 
mediately beneath the epithelium covering a mole. In the pigmented moles these 



GENERAL SURGERY 295 

cells have pigment in and about them. It is a debated question whether these 
mole cells are really epithelium or connective tissue, and there has always been 
much discussion as to whether these tumors were melanosarcomata or melano- 
epitheliomata. The more recent opinion seems to be that they really have an 
epithelial origin. They may occur anywhere on the surface of the body; they are 
not often found inside the body, although other melanotic tumors do occur. 
Broders and MacCarty have divided these tumors into two classes — the non-pig- 
mented and the pigmented. Sometimes the partial removal of a pigmented mole 
will start a melanoepithelioma, or it may start spontaneously. The gross appear- 
ance may show a large fungating mass of dark colored tissue or a small raised area 
resembling a blood blister, with the main mass of the tumor lying deep. On sec- 
tion one may find a single mass of black tissue, or there may be an unequal distri- 
bution of the pigment. Microscopically at the edge of the tumor one can generally 
observe the continuity with the normal epithelium, but the cells of the main 
tumor show very little differentiation. They very quickly lose the normal appear- 
ance of squamous epithelial cells and often resemble sarcoma cells. The cells are 
large and generally show many mitotic figures. One may see small areas packed 
with pigment and other areas with no pigment at all. The pigment may be within 
the cells or outside of the cells. It is a very malignant tumor, with 100 per cent 
mortality. It metastasizes very rapidly to the lymphatic glands, and may spread 
all over the body. It is curious that sometimes the metastases have no pigment at 
all, whereas the tumor itself is full of pigment, or vice versa. 

ADAMANTINOMA 

The adamantinoma is a tumor of squamous epithelium which apparently 
originates from the enamel organ at the root of a tooth. The gross appearance is 
that of a tumor which may become as large as an organ. It is more often found 
in the lower jaw than in the upper. It has a thin bony shell on the outside, and on 
section shows many cystic cavities filled with yellow degenerated material. Under 
the microscope it presents a very definite picture. It consists of masses of squa- 
mous epithelium, the outer or basal layer of which is very dark-staining. The nuclei 
are round or oval and the basement cells are cylindrical. Inside this layer the cells 
are first cuboidal and then squamous. In the center there is a degenerated area 
which may either be filled with cellular debris or may be empty, forming a cyst. 
They are relatively benign tumors, and if the gross tumor is removed, they do not 
recur. 

MIXED TUMOR 

Broders and MacCarty have also described a mixed tumor which occurs rather 
infrequently in the palate. This is a mixture of squamous and glandular tumor 
tissue, and is so relatively infrequent that I will simply mention its occurrence. 



DISCUSSION OF SURGICAL ASPECTS OF EPITHELIOMA 

Participants: 

Dr. Theodore Tuffier 
Dr. Adrian S. Taylor 

Dr. Tuffier: Dr. Taylor has asked me to examine this patient, a woman of 
middle age, who has never had a serious disease. She now has a tumor of the tongue 
in the posterior third, on the right side. It is only a little more red than the tongue 
itself. There has been very little pain, nor is it painful when I put my finger upon 
it. All the movements of the tongue are free and without pain. In this location on 
the tongue such a small tumor can be acute or chronic. This is chronic. One year 
ago the patient noticed a little pain in that part of the tongue. She consulted a 
dentist, who found one tooth that caused pain and removed it. The tumor did not 
disappear, but it has not enlarged. 

We must know the diagnosis, the prognosis, and the treatment. I have seen 
three patients in my experience who had this kind of tumor. You all know that in 
such a position a very small lesion may be very painful. There are many patients 
who come and say that they have a bad tumor of the tongue which is very painful. 
You examine them and find nothing at all. They come again, and finally you find 
a small tumor which gives very great pain. In those cases the tumors are not really 
tumors; they represent an irritation of one very small part of the tongue, with 
great pain, and leave no bad results. I have also seen an adenoma of the tongue. 

It is very unusual to see a cancer of the tongue in a woman. Such a diagnosis is 
very likely to be a mistake. When a woman is a smoker or syphilitic there is a 
cause of irritation; but in my experience I have seen only two cancers of the 
tongue in women. When Dr. Taylor told me his patient was a woman I im- 
mediately said, "Then probably it is not a cancer." This tumor has been in the 
same location and position for one year, and I have never known a cancer of the 
tongue to go on for one year without increasing in size. When you have a tumor 
going on for one year, in the same situation, without bleeding, without increasing 
in size, there is a great chance that it is not cancer. 

This tumor appears to be hard but when you take it between two fingers it is 
not; it is elastic and can be moved very easily. Palpation proves that it is not a 
cancer. If you are in doubt as to cancer, what are you going to do? The tumor does 
not go deep but remains superficial, it is movable, elastic, and is not raised. With 
this condition present I believe the patient has an adenoma of the tongue and not 
a cancer. The prognosis really depends upon the surgeon. If you do not remove 
the cause of the chronic irritation or use a cautery, the condition may develop into 
cancer, as in other parts of the body. But without treatment it is probable that it 
will remain in the same situation for some years. 

It is very difficult to say what is the best treatment for cancer of the tongue. 
When you use surgery you remove all the tumor. When you use X-ray you kill 
the cells in certain places. When you use radium you also kill the cells in certain 
places. I believe that a cancer of the tongue calls for radical treatment by surgery. 

The first cause of cancer is a biological one. I believe, after an experience of 

296 



GENERAL SURGERY 2 gy 

forty-five years, that very often the cure is partly medical — not entirely surgical. 
You must remove, if possible, the conditions that have caused the cancer. I think 
that radical treatment is indicated. If you could change the serum, or change the 
blood — if you could change the condition of the patient — you might arrive at a 
medical cure. But being unable to treat the condition medically we must do what 
we can for the patient by surgery, by X-ray, or radium. We do not know the cause 
of cancer of the tongue. I have operated on a great many cancers in my life, and 
I have had good results in some cases in which I have done the same operation 
that I have done in the case of patients who have died. It was certainly not be- 
cause of my surgery, but because their condition was better. I have had four cases 
that recovered after fourteen years — why, I do not know — I did the same 
operation, the tumors were the same, and as large as the others. I believe that 
surgery is the best means we have; but even with surgery you cannot say that 
you will have a recovery. 

I believe that in a cancer of the tongue the best thing to do it to remove all the 
glands above the clavicle at the first operation, and at the second operation to 
remove as much of the tongue as possible. But there is an element of uncertainty 
in the result. 

In regard to the use of radium and X-ray, during ten years' experience I have 
seen radium used in many cases. There is a stage, in a small tumor of the tongue, 
in the deep part near the throat, when you can do better with radium than with 
the knife, because with the knife you can never remove very well all the tissues 
around the tongue. X-ray has given less definite results. The X-rays we were using 
about two years ago were not sufficient for recovery. I believe that the knife is the 
best after all, for it is very difficult to know the exact dosage of the X-rays. If 
you give too much X-ray it is possible to produce an irritation. (Irritation is per- 
haps the word. When we do not know what else to say we use the word irritation. 
But what is irritation? Is it a microbe? We do notknow.) The same is true of 
radium, for you may cause a very bad condition of the tongue if you use radium 
in great quantities. In the presence of very extensive growths which I could not 
remove, I have tried radium. One patient was a physician with a very extensive 
ulceration of the tongue, who asked me to use all the radium we could. With the 
help of two of my friends I got tubes of all the radium we could find in Paris and 
put them in all parts around the tumor. This case was very curious and very dis- 
appointing. At first the patient seemed much better, but he developed symptoms 
of acute intoxication and died of intoxication coming from dead tissue. So, when 
we use a small quantity of radium we do not get good results, because it is not 
sufficient to kill the tumor cells; when we kill a large tumor at once by a large 
quantity of radium we have death from intoxication. 

If this woman has a cancer of the tongue what is to be done for her? I believe it 
is best to remove the small tumor and to do a suture by first intention. The reason 
I say that an operation is the best thing in this case is because I think the tumor 
can be safely removed. I have not seen complications in such cases. And when you 
can remove such a tumor in the case of a woman who is fifty-one years old, and 
the operation is absolutely without danger, without risk, it is better to remove 
the tumor than to leave it. It is the same in many diseases. When you operate 
for appendicitis, you remove the appendix because it is less dangerous to remove 



298 PEKING UNION MEDICAL COLLEGE 

it than to leave it in place. In this case if the tumor is left, it is possible that after 
some months or some years the patient will have a cancer of the tongue. And so I 
believe that the best thing to do is to operate. 

For a condition of the tongue that is very painful and without a tumor I think 
that cocainization is the best thing, and that the patient has more a tumor of the 
mind than of the tongue. Such patients are very often neurasthenic. In the case 
of an adenoma I believe that it is better to remove it than to leave it in place. 

Dr. Taylor: I wish to emphasize a particular point, because we have had 
two cases along these lines recently. In the case of the patient whom you see this 
morning we received a letter and telegram from friends in Korea asking our ad- 
vice, stating that the patient was a woman fifty years old, who had a small growth 
of the tongue. The advice we gave was to make a definite diagnosis and to be 
prepared to carry out the treatment required by that diagnosis, and not to take a 
section from the growth and send it to us for diagnosis. In the other case a small 
piece of tumor was sent to this institution for diagnosis. The tumor proved to be 
an epithelioma. We sent the report back and the patient immediately started 
for Peking. There was an interval of not over two or three weeks from the time 
the specimen was sent us until the patient arrived in Peking, but during that in- 
terval the growth had recurred in situ — that is, in the scar. A radical operation 
done at that time revealed metastasis in a lymph node along the internal jugular 
vein. 

I should like to say a few words in regard to the type of anesthesia we use. A 
friend spoke to me the other day of etherization by rectum. I think this is justifi- 
able if you cannot do better, but I believe that it is not the safest type of anesthe- 
sia for work around the mouth. We use the Connell ether machine, and we are 
able with it to regulate accurately the ether vapor tension. It has been found that 
if the proportion of ether mixture be kept constant, the depth of anesthesia is 
constant and regular. These machines are rather too complicated and expensive to 
be used in the ordinary mission hospital; they cost four or five hundred dollars 
gold. And then, too, such hospitals have not the necessary compressed air and 
electricity to run the machine. But one can improvise a very satisfactory ether 
machine with a glass bottle and rubber bulb. With ordinary satisfactory etheriza- 
tion, with the patient in the head-down position, the operation of the tongue is 
easily carried out. 

Dr. Welch spoke to me a few minutes ago about the incidence of syphilis in 
these tumors of the tongue and also about the extreme rapidity of growth of 
carcinoma in the glands of the neck, and the poor prognosis, especially in cases 
with syphilis. In reading up these cases in recent literature, I found that very soon 
both sides of the neck become affected. One should, therefore, be prepared to 
clean out the glands on both sides of the neck, especially if the growth is in the 
posterior one-third of the tongue. 

Now, if this tumor were malignant it would be in a very bad location. The 
prognosis is far worse for a growth in the posterior third of the tongue than for a 
growth in some other portion. 

I have recently done the complete operation at one sitting, without difficulty. 
What is the danger of the complete operation? First, it is a major procedure. In 
the second place, there is the danger of infection. One does not try to save the 



GENERAL SURGERY 299 

platysma muscle. Everything under the platysma muscle is removed en bloc by 
sharp dissection. The incision follows a crease in the neck, with a right-angled 
prolongation downwards. The platysma is not reflected with the skin, as in benign 
conditions of the neck. The skin alone is reflected, and the platysma excised at the 
limits of the wound. There are four groups of lymph glands — the submental 
glands, the submaxillary glands, the glands at the tip of the parotid, and the 
glands that go down along the jugular vein. Every surgeon has his own way of 
dissecting the neck. It is usually very easy to begin with the submental and the 
submaxillary glands and then to work backward to the glands at the tip of the 
mastoid. Of course here one must not cut the main branch of the facial nerve. It 
is perfectly justifiable to cut the third branch of the seventh nerve. As a matter 
of fact, I do not think that a radical operation can be done here and the third 
branch of the seventh nerve be saved. Then the jugular vein is dissected out. One 
may or may not save the vein. It is easy to dissect it safely, and in a radical dis- 
section it is also justifiable to tie the vein low down and take it out with the mass 
of glands one removes. However, where one is going to do both sides of the neck 
it is not safe to take out the vein on both sides. With a sharp knife and careful, 
gentle dissection it is easy to strip the vein clean. 

In the case done two weeks ago we did a radical operation at one sitting. The 
dissection of the neck went rapidly, without loss of blood. We excised the tongue 
at the same time, and the only complication we had was a very slight infection in 
the submaxillary region, where there was a light leakage of saliva for a few days. 

The point I should like to make this morning is that one should not cut into 
these suspicious tumors of the tongue unless one be prepared to go the entire 
length and do a radical operation. The technique of frozen sections, which Dr. 
Meleney will demonstrate this morning, is available for everyone. One should 
make up his mind pretty definitely before he makes a frozen section as to the type 
of growth, and be prepared to do the radical operation or to do no operation at all. 



THE PREPARATION AND USE OF DAKIN'S SOLUTION 

Participants: 

Dr. Adrian S. Taylor 
Dr. Theodore Tuffier 

preparation of dakin's solution 

Dr. Taylor: Dakin's solution is a solution in water of sodium hypochlorite 
(NaOCl) which contains not less than 0.4 per cent, nor more than 0.5 per cent, 
sodium hypochlorite, and which is not alkaline to powdered phenolphthalein but 
is alkaline to an alcoholic solution of phenolphthalein. If the percentage of sodium 
hypochlorite is less than 0.4 per cent, the antiseptic power of the solution is too 
low; if greater than 0.5 per cent the solution is too irritating. If the solution is 
alkaline to powdered phenolphthalein, the solution is irritating; if the solution is 
neutral or acid to an alcoholic solution of phenolphthalein, the solution is un- 
stable. 

The solution may be made in several ways: (1) from bleaching powder; (2) 
from chlorine gas and sodium carbonate; and (3) by electrolysis of a solution of 
sodium chloride. The first method, fully described in the literature, involves the 
determination of the chlorine content of the bleaching powder available, then the 
addition to a suspension of the bleaching powder in water of sodium carbonate. 
The amount used depends upon the chlorine content of the bleaching powder 
available. The reaction produces sodium hypochlorite and caustic alkali. This 
excess alkalinity is reduced in various ways. This method is father unsatisfactory 
on the whole. From several cities in China word has come that bleaching powder 
of proper chlorine strength is not available. 

The second method requires chlorine gas. This may be made locally in the 
usual way from common salt, sulphuric acid, and manganese dioxide, or it may 
be bought compressed in steel cylinders. Liquid chlorine gas is not made in China 
as far as we know, and as it is "deck cargo" it is expensive and difficult to obtain. 
The reaction between sodium carbonate and chlorine gas is a simple one, and the 
resulting product is the sodium hypochlorite desired. The amount of chlorine gas 
needed for a given amount of sodium carbonate to produce a solution of sodium 
hypochlorite of any desired strength is easily determined from the simple reaction 
involved. These figures are given in tables available in the literature. The gas 
itself is usually measured by means of a simple calibrated meter manufactured by 
Wallace and Tiernan Company, New York. The gas used may be actually weighed 
by blowing it through a solution of sodium carbonate in a tarred bottle, balanced 
on a scale. 

In the third method a direct current of electricity of known strength is run 
through a known saline solution for a given time, and a solution of sodium hypo- 
chlorite in water of definite strength results. Cells for the electrolytic manu- 
facture of Dakin's solution are on the market. 

As the action of Dakin's solution depends on the chlorine content and on the 
alkalinity, determinations of both are necessary. The percentage of sodium 
hypochlorite is determined by titration with 0.1 n sodium thiosulphate, adding 

300 



GENERAL SURGERY 301 

potassium iodide and acetic acid to the Dakin's solution in order to give a visible 
index of the chlorine present. When potassium iodide is added to a solution of 
sodium hypochlorite in the presence of an acid, a double decomposition takes 
place, and free iodine is thrown down, one atom of iodine for each atom of chlorine 
present. The iodine thrown down is then easily determined by titrating with the 
0.1 n sodium thiosulphate. 

The degree of alkalinity must be exact, as a solution too alkaline will prove 
irritating to the tissues, while one too nearly neutral will be unstable. The ideal 
solution must give a definite pink reaction to an alcoholic solution of phenol- 
phthalein, but must not give a color when the dry powder is added to it. 

The action of Dakin's solution in a wound is two-fold. It has a bactericidal 
action, and is also definitely solvent for necrotic tissue in the wound. The bac- 
tericidal action depends upon the chlorine content; the solvent action depends 
upon the sodium hypochlorite and upon the alkalinity of the solution. 

DEMONSTRATION 

The preparation of Dakin's solution from liquid chlorine gas and sodium car- 
bonate was shown. A specimen was examined and the percentage of sodium hypo- 
chlorite determined by titration. The alkalinity was tested, and was found to be 
between the end points for phenolphthalein, dry and in alcoholic solution. 

USE OF DAKIN'S SOLUTION BY THE CARREL METHOD 

Dr. Tuffier spoke of the introduction and use of Dakin's solution by the 
Carrel method during the war and its use in civil cases, particularly in empyema. 
He brought out the following points: 

1. There must be contact with every part of the wound. If one part is not 
reached it will later be the source of reinfection for the whole wound. 

1. Bacterial counts must be made every three or four days. Several parts of the 
cavity must be examined, because one part may become sterile and another part 
still hold its infection. 

3. In those cavities where one cannot bring about contact of Dakin's solution 
with every part, an attempt must be made to alter the patient's serum in order to 
combat the disease. This may be done by either an autogenous or a stock vaccine; 
or by "proteinic shock." This is particularly important in bone or fat tissue 
infection. 

4. The most important quality of Dakin's solution is its ability to dissolve dead 
tissue. Thus large quantities of bacteria are washed out, and sloughing tissue, 
which is the food for bacteria, is removed. This permits the body to destroy the 
bacteria with which the living tissue comes in contact. 

DISCUSSION 

In the general discussion other points were brought out as follows: 
1. Wounds infected with streptococci are slower in becoming sterile than those 
where other organisms are present. For that reason cultures as well as bacterial 
counts are necessary. If streptococci are present the wound cannot be secondarily 
closed. 

1. The granulation tissue which grows under Dakin's solution is red and firm 



302 PEKING UNION MEDICAL COLLEGE 

and flat. It does not tend to be exuberant. Skin grafts may be made upon it 
easily and successfully. 

3. Dakin's solution can be used with benefit in tuberculous empyema but will 
not result in a closure. The patient gains in general health and strength. The same 
can be said of psoas abscess. 

Dr. Tuffier: I will say just a few words about the use of Dakin's solution for 
the sterilization of wounds and of the cavity in empyema. In empyema we put 
the patient on his good side and wash out the cavity with the solution. That is 
very good in the beginning, but after twenty-five or twenty-six days vaccination 
is done. At the moment when the growth of the microbes ceases you can close the 
cavity. So for empyema you wash the large cavity with many tubes; and when 
the growth of the microbes, examined every three or four days, drops to one 
microbe per field under the microscope you can discontinue the Dakin's solution 
and close the cavity. The cavity is sterilized and the battle is won. 

Where you have a very large cavity in the pleura and a bronchial fistula, you 
cannot use Dakin's solution, because the solution gets into the bronchus and the 
result is bad. In such cases you can do one of two things. Either before washing 
out the cavity the fistula may be plugged with a small piece of gauze, and when 
it is obliterated the cavity may be filled with Dakin's solution; or the patient 
may be turned on the bad side, so that when the cavity is irrigated, the solution 
will not get into the bronchus. You can do this in some instances, but with some 
fistulas you cannot use this solution. In those cases you can sterilize by oxygen. 
You do exactly the same thing as by the Carrel-Dakin method. You distribute 
through all parts of the cavity ten or twelve tubes, or even more. You pass a cur- 
rent of oxygen through all the tubes. That is sufficient for the disinfection of the 
cavity. The oxygen gets into the bronchus; you have no injury and no trouble 
for the patient. 

These are the two methods. Certainly Dakin's solution is a very good solution 
for the disinfection of all cavities, but the great difficulty is to insert as many 
tubes as are necessary. If there is one part of the pleura where the solution does 
not reach you can be sure that the cavity will not be sterilized. The cavity may 
be sterilized save in a few deep inaccessible pockets. Search in these recesses with 
a long wire loop, with the cavity well illuminated, usually reveals sites of hidden 
infection. Tubes placed so as to reach such spots often lead to final and complete 
sterilization. 

But this is only one condition. I have seen Dakin's solution used in numerous 
other wounds during the war; and it was certainly a very great blessing. And I 
have used it in experiments in my laboratory in Paris. The method is very diffi- 
cult; the solution is not always good, and as Dr. Taylor has very well said, you 
must have the exact solution. That has been demonstrated by The Rockefeller 
Institute in New York, to which we certainly owe a great debt. 

For disinfection of a wound of an extremity or of the pleura the procedure is 
the same. We have three methods. One is by "absorbing" the microbe, one is by 
killing the microbe by an antiseptic, one is by vaccination. We believe that the 
growth of infections — surgical infections — can be stopped by changing the 
composition of the serum of the blood. For this we have two methods. First, 



GENERAL SURGERY 303 

vaccination. For a special microbe we have the autogenous vaccination. But we 
have another alternative. If you change the composition of the serum of the blood 
by a chemical substance or a protein substance you can secure very good results 
and can see the infection decreasing. I am certain that this is so for an abscess of 
the breast, for some forms of pleuritis, for some diseases of the fatty tissues, for 
some diseases and infections of the bones. You know that the microbes are living 
in the blood and in the tissue, because around the microbes is a space where they 
are not touched by any substance, and when you inject a vaccine or protein 
substance there you give the blood the power to overcome the microbe. When the 
microbe is touched by the blood or plasma it is killed. 

Dakin's solution is a very good disinfectant for washing the wound and taking 
off all the bad cells. We were certainly very grateful to the Rockefeller Founda- 
tion in Paris during the war for its assistance in supplying it. In the beginning 
Drs. Carrel and Dakin were working under very great difficulties; they could not 
do all the experiments that they wanted to do. We lost at least seven months 
and more than ten thousand men by this handicap. 

DEMONSTRATION 

Dr. Taylor here showed the materials used in making up the apparatus 
required for the use of Dakin's solution. He called attention to the importance of 
observing the minutiae of the technique as taught by Carrel. A number of infected 
wounds being treated by the Carrel method were shown and a large granulating 
wound, treated by Dakin's solution, was grafted by Dr. Char. The front of the 
thigh was anesthetized by injecting a 0.5 per cent solution of novocaine into the 
region of the femoral and lateral cutaneous nerves of the thigh just below Pou- 
part's ligament. The grafts were small pinch grafts raised with the point of a fine 
straight needle, and cut with a sharp scalpel. The wound after being dressed was 
covered with a piece of paraffined gauze, over which a gauze compress moistened 
with saline solution was placed. 

DISCUSSION 

Dr. Tuffier called attention to the necessity for frequent bacterial counts. He 
said that a platinum loop on a glass handle is used to secure smears from all parts 
of the wound. Bacterial counts are made frequently, and graphic charts of the 
counts are kept for each patient. 

Question: Do you use Dakin's solution for an overgrowth of granulation 
tissue? 

Dr. Taylor: In our experience there is little tendency toward the overgrowth 
of granulation tissue when Dakin's solution is used in a wound. Here the granu- 
lations are firm, pink, and close together. They make an excellent base for skin 
grafting after Reverdin's method. In very dirty, necrotic ulcers the curette is 
frequently used in preliminary treatment, or the ulcer is actually excised, or in 
some cases the base is swabbed with pure carbolic acid followed by tincture of 
iodine before the Dakin's solution is started. 

Question: Is the Dakin's solution used continuously? 

Dr. Taylor: No. As a rule the tubes are flushed every two hours. In some 
cases, when we have flat, open ulcers, compresses soaked in Dakin's solution are 



3o 4 PEKING UNION MEDICAL COLLEGE 

changed by the nurse every two hours. In large empyema cavities, the patient is 
turned on the sound side and the cavity filled with Dakin's solution, which is 
allowed to remain in the cavity for about twenty minutes. This is done every two 
hours. Of course if there is a bronchial fistula, this cannot be done. The procedure 
spoken of by Dr. TufHer a few moments ago may be tried. 

Question: Have you had any experience in the use of Dakin's solution in 
tuberculous pleuritis? 

Dr. Tuffier: In these cases the general condition of the patient is greatly 
helped by the use of Dakin's solution, but we seldom have a cure of the tuber- 
culous pleuritis. 

Dr. Taylor: Our experience has been similar. During the past year we have 
treated several of these cases without a death and with marked improvement. In 
no case, however, have we had a permanent closure of the fistula. 

Visiting Surgeon: During the war we had large numbers of Chinese coolies 
in our care. Many of these had very extensive tuberculosis of the pleura. We used 
to fill up the cavity with the solution. Of course they all died. Most Chinese with 
tuberculous pleurisy do die. 

Question: Do you use Dakin's solution in psoas abscess? 

Dr. Taylor: In view of the impossibility of reaching the site of the infection 
in such cases, we do not use Dakin's solution. 

Question: Is the solution stable in sunlight? 

Dr. Taylor: The stability of Dakin's solution depends largely upon the 
alkalinity. If it gives a definite pink color with an alcoholic solution of phenol- 
phthalein, it will be fairly stable even in white bottles in the ward. Direct sunlight 
has a moderately deleterious effect upon it. Potassium permanganate is often 
added to the solution to give it a faint pink color. This is simply to heighten its 
visibility and has no other effect, good or otherwise. We here insist upon daily 
estimation of the strength of the solution we are using. Titration takes a moment 
only. The amount of o.i n sodium thiosulphate solution used in the titration is an 
index of the chlorine strength. 

I have here large graphic charts, which we shall be glad to distribute. These 
charts give at a glance the percentage of sodium hypochlorite (NaOCl) in any 
solution examined. 



OPERATIVE CLINIC 

Participants: 

Dr. Theodore Tuffier 
Dr. Adrian S. Taylor 

CASE I. ANKYLOSIS OF HIP. DR. TUFFIER 

A male Chinese. Nine months previous to admission he had an acute onset of 
some inflammatory process in the right hip. The pain and swelling lasted three 
months and then subsided. Contraction of the thigh then began. On admission 
the thigh was found flexed to an angle of 120 , adducted, and internally rotated. 
X-ray examination showed an old posterior dislocation with the head of the femur 
ankylosed to the ilium and ischium. 

Operation. Vertical incision on latero-posterior aspect of thigh, exposing upper 
third of femur. Wedge-shaped piece through entire thickness of the bone removed 
below great trochanter with base of wedge latero-posterior. By alternate flexion 
and extension the thigh was brought down to an angle of 20 with the vertical. 
Patient to be put in Balkan frame, with traction to perfect the alinement. 

Dr. Tuffier made the following observations upon cases of this kind. The old 
infected area of the joint must be left alone. The base of the wedge removed 
should be in such a position that the adduction and flexion deformity may be best 
corrected and the cut bone surface lie in as close contact as possible when the leg 
is straight. More primary extension at time of operation may be obtained by 
alternate flexion and extension than by simple extension. Further stretching of 
the muscles and alinement must be obtained by traction. 

CASE 1. ADENOMA OF THYROID. DR. TAYLOR 

A female Chinese, aged thirty-two, married, presented herself for relief because 
of a large growth in the right side of her neck. This growth was first noticed ten 
years ago, and had slowly and continuously increased in size. No symptoms had 
been noticed other than those attributable to the mechanical pressure. 

Examination showed a typical unilateral adenoma of the thyroid. No evidence 
of hyperthyroidism could be found. The tumor occupied the right lobe of the 
gland and was the size of a large orange. 

Operation. Attention was called to the following points in the operative pro- 
cedure: A transverse collar incision was made low down in the neck in a skin fold, 
and flaps of skin and platysma were reflected. The sterno-hyoid muscle was 
separated from the underlying sterno-thyroid, and then the latter muscle was dis- 
sected away from the gland. Ample exposure was obtained by retraction without 
division of either muscle. 

Tissues were gently pushed back along the lateral aspect of the gland with a 
Kiittner gauze dissector. This manoeuvre was used to demonstrate one of the 
means of protection of the recurrent laryngeal nerve. After this dissection, the 
lobe of the thyroid containing the adenoma was easily raised from its bed. The 
vessels at the superior pole were caught and divided between clamps after they 
had entered the gland substance. Other straight clamps were placed on vessels 
21 305 



306 PEKING UNION MEDICAL COLLEGE 

along the lateral aspect of the gland, the vessels being caught "intracapsularly. " 
These clamps hanging to the capsule formed a line posterior to which all tissues 
were reflected. In this way, the danger of injury to the nerve and the parathyroid 
bodies was minimized. The capsule was incised from above downward, superficial 
to the line of clamps, and the large adenoma was excised with a moderate amount 
of normal parenchyma, the line of excision being superficial to the posterior layer 
of the capsule. As the midline was approached, the vessels in the medial aspect of 
the capsule were likewise clamped with the edge of the fibrous capsule. Several 
perforating vessels in the body of the gland required individual ligation. Hemosta- 
sis was secured by fine black silk, transfixed in a figure-eight fashion through each 
vessel or bleeding point. The medial and lateral cut edges of the capsule were 
brought together with silk over the raw surface superficial to the posterior layer 
of the capsule. Muscles and fascia were brought together in the midline with fine 
silk, and the platysma was closed with a few buried interrupted sutures of the 
same silk, the knots being tied on the under surface of the muscle. The skin was 
closed with fine silk interrupted. Perfect hemostasis was secured, and drains were 
not used. Short straight needles, 1.5 cm. in length, were used for the transfixion 
sutures in the depths of the wound. The special needles, the clamps, and retractors 
used in this operation were designed by Halsted many years ago, and the opera- 
tion itself followed the lines laid down by him (1). 

BIBLIOGRAPHY 
I. Halsted, W. S., The operative story of goitre, Baltimore, 1919. 



DEPARTMENT OF OBSTETRICS AND GYNECOLOGY 



SUMMARY 

Participants: 

Dr. J. Preston Maxwell 
Dr. John G. Clark. 
Dr. David E. Ford 
Sir William J. Smyly 
Dr. Jean I. Dow 
Dr. Arthur W. T. Woo 
Dr. Frank. F. Simpson 
Dr. Paul H. Stevenson 

Friday, September 16. Dr. Maxwell read a paper on the interesting cases of the 
past year, the first year of the newly opened Women's Clinic, illustrating the 
paper by radiograms, macroscopic and microscopic specimens, and drawings. 
The special features of the paper were the discussion of antenatal work with 
special reference to a case of migraine with hemianopsia; cases of toxemia in 
pregnancy, with special reference to three cases of threatened eclampsia; cases of 
Caesarian section, with their indications and details of technique; some gyneco- 
logical cases, including a case of sarcoma commencing in a uterine fibroid and 
recurring after a panhysterectomy; an unusual case of fibroid polypus; and 
certain pathological specimens acquired during the year, some from within and 
some presented to the College. Discussion followed the reading of the paper. 

Saturday, September iy. The Section met in the operating theatre. Dr. Clark 
operated on a case of vaginal cyst and discussed its origin and treatment. He then 
proceeded to give the Section a demonstration of the best methods of performing 
plastic operations on the vagina, illustrating his remarks by means of plasticine. 

A case of procidentia was also shown and discussed. 

Monday, September ip. Dr. Ford introduced a discussion on the measurements 
of the Chinese pelvis, summing up our knowledge of it, and giving details of the 
results which had been so far published on the subject. Discussion followed and 
a small committee was nominated by the Chairman, who reported later as to a 
uniform table which might be used for the recording of the measurements. The 
principal forms of contracted pelvis met with in China were also mentioned. 

Sir William J. Smyly then read a paper on "Eclampsia and Eclampsism," 
which was followed by discussion. 

Tuesday, September 20. Dr. Clark gave a lecture on uterine hemorrhage, its 
causes and treatment, illustrated by diagrams on the blackboard. He dealt 
especially with the relation of such hemorrhages to the menstrual cycle and also 
discussed in detail the use of radium in gynecology and its effects in malignant 
diseases of the uterus. 

By the use of plasticine, Dr. Clark demonstrated an operation for sterility, by 
opening the uterine horn, no sutures being used to unite endometrium to peri- 
toneum. 

Discussion followed. 

309 



310 PEKING UNION MEDICAL COLLEGE 

Wednesday, September 21. Dr. Dow read a paper on her maternity work in the 
famine area, with statistics of 429 deliveries and particulars as to the condition of 
the patients and means of handling them. Others also spoke on the same subject. 

Dr. Woo then demonstrated the use of his modification of Reverdin's needle. 

Two cases of chondrodystrophia fetalis were shown to the Section, and a 
radiogram of one of these cases. 

Thursday, September 22. Dr. Stevenson read a paper on the prevalence and 
causation of abortions. Discussion followed. 

The Section then adjourned to join the Section of Pathology in the considera- 
tion of a case of syncytioma presented by Dr. Henry E. Meleney and illustrated 
by lantern slides. Discussion followed on the diagnosis and treatment of these 
cases, the case shown being a rare one where death had taken place from sepsis 
and not from metastasis. There had been, however, hemorrhages on various 
occasions during the course of the illness, and the invasion of the uterine wall by 
large syncytial cells was well shown in the sections. 










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INTERESTING CASES OF THE YEAR 1920-21 

By 

J. Preston Maxwell, M. D. 

INTRODUCTION 

Before commencing the subject which we are to discuss this morning, let me 
welcome you all to the meetings of this Section. The Department under whose 
auspices these sectional meetings are held, owes much already to the kindness of 
those who are working in China, and I would again invite your hearty co-opera- 
tion in sending to us specimens of pathological interest, especially tumors, fetuses, 
monstrosities, and the like. We are prepared to examine any pathological material 
sent to us, giving the sender a diagnosis at as early a date as practicable, but we 
would beg that the essential clinical data of the cases be sent to us at the same time 
as the material. As you perhaps know, several years ago it was found necessary 
to suspend the women's work, both out-patient and in-patient, at the Union 
Medical College; and in view of the difficulty of restarting a work of this kind in 
China I thought that a review of the interesting cases of the first year's work 
might appeal to you. Some of the cases quoted may seem to you to be common- 
place, but it is not the rare cases only which are interesting and instructive. A 
modern obstetrical department is not complete without its antenatal side, and 
so we begin with the consideration of several cases which raise problems of 
importance to us all. 

PROBLEMS OF PREGNANCY 

No case of serious vomiting of pregnancy has been encountered during the 
year, but quite a number of cases have been under treatment for the subacute 
form. Corpus luteum extract has been given these patients in doses of i grains, 
three times a day, and has proved very satisfactory both in primiparse and 
multipara;. In dealing with a symptom of this kind which undoubtedly has its 
psychological aspect, it is difficult to estimate the value of a drug, but several 
patients, after using it for a few days, have begged for a further supply, and were 
emphatic as to the relief it gave them. In one case the corpus luteum in pill form 
led to acute and immediate vomiting, but in this case the same drug given by 
injection proved very efficacious. This patient's first pregnancy had ended in a 
hydatidiform mole, accompanied by pernicious vomiting for several weeks; but 
the second pregnancy is now well on its way without any untoward symptoms 
having presented themselves. 

Two cases of intense salivation were not relieved to any marked extent, but 
improved of themselves as the pregnancy went on. 

Three cases of definite pregnancy toxemia have been under treatment by the 
Department. The first of these, a secundipara in the thirties, developed eclampsia 
in her first pregnancy and had a Caesarian section performed three weeks before 
time. In this pregnancy she developed albumen and acetone in the urine at the 
seventh month. Saline injections by the bowel, sodium bicarbonate by the mouth, 
and abstinence from all meat, fish, and eggs cleared the urine, and she was con- 

3" 



312 PEKING UNION MEDICAL COLLEGE 

fined without any untoward occurrence a fortnight after her proper date of 
delivery. There was no sign of the Caesarian scar to be felt, but special care was 
taken to avoid overaction of the uterus, and the patient was delivered by forceps. 

The second case was a primipara, aged twenty-four, who developed a small 
amount of albumen in the urine a few days before labor. There was also a slight 
degree of edema of the ankles and legs, with a measure of restlessness which was 
abnormal. Labor was precipitated by a dose of castor oil and quinine, and the 
albumen cleared up satisfactorily, though she gave us trouble with mastitis, 
increased by inverted nipples. 

The third case was a secundipara who some hours after her first child was 
delivered, had an eclamptic convulsion, was comatose for forty-eight hours, and 
extremely ill. During the early months of this pregnancy she suffered much from 
headache which was relieved by abstinence from meat and fish. During the last 
month she developed much edema, a small amount of albumen, and an occasional 
cast, and the headaches began to reappear. As matters were not improving, labor 
was induced by bougies about a fortnight before time and she did excellently. 

Two other curious accompaniments of pregnancy were encountered during the 
year. The first of these was in a case under the care of Dr. Douglas Gray. The 
patient was a secundipara, and towards the latter part of her first pregnancy she 
had developed an intense gastrodynia, which cleared up as soon as the child was 
delivered. In the present pregnancy this symptom had reappeared at about the 
sixth month and the attacks of pain were most severe, irregular in appearance, 
caused by any article of food or drink, or sometimes coming on independently, 
and the worst attacks were relieved only by morphia or opiates. There was no 
sign of any organic disease either of stomach, gall bladder, or kidneys. Towards 
the end of pregnancy these attacks of pain improved very much and Dr. Gray in- 
formed me that they entirely ceased after labor. 

The second was a patient, aged thirty-two, the wife of a doctor, who referred 
her to the Department because of certain abnormalities which had occurred 
during the pregnancy. She had been married seven years, had one healthy living 
child, and there had been one miscarriage. In 1909 she had an attack of hemian- 
opsia with intense headache but recovered after a day in bed. In 191 1 while on a 
holiday, she had a second attack with headache and some confusion of speech. 
In 191 5 during the first days of pregnancy, she had very severe headache, a little 
temperature, and the right arm was numb for twenty-four hours. In 1916 she had 
one attack like that of 191 5. In 1917 just before the miscarriage, she had an 
attack of hemianopsia, confusion of speech, and numbness, mostly in the hand. 
In November, 1920, she had an attack of diarrhoea and was ten days in bed. After 
being up two days she had an attack of hemianopsia with nearly total loss of 
vision, partial loss of power of speech, using wrong words, much distressed in 
consequence; numbness of hand, arm, and leg, and slightly of the right side of the 
face; neuralgic pains over the left side of face and hand; recovered after twenty- 
four hours. In the eighth week, twelfth week, and sixteenth week of this preg- 
nancy she had uterine hemorrhages lasting from three days to a month. In the 
twenty-third week she had another attack of hemianopsia, numbness of right 
arm and hand, difficulty in getting the right word, the condition lasting about 
half an hour. 



OBSTETRICS AND GYNECOLOGY 313 

On examination the child was found lying in breech presentation and the 
patient's general physical condition was good. Dr. Howard examined the eyes 
and found a normal fundus with two degrees of myopia and a good deal of myopic 
astigmatism, and was of the opinion that the eye symptoms were due to mi- 
graine. Dr. Woods examined the patient from the neurological side and came to 
the same conclusion in regard to the nerve symptoms. Attempts at external 
version failed and so I allowed the case to proceed as a breech. She delivered 
herself of a living child, breech with extended legs, although there was no sign of 
this extension in an X-ray photograph taken a few days before labor. Presenta- 
tion was a right sacro-posterior, the right buttock rotating to the front. Since 
delivery the end of June, she has had one slight attack without eye symptoms 
but attended by headache and numbness, the attack supervening as many of the 
others have done, on fatigue and worry. 

OBSTETRICAL WORK 

Turning to the actual obstetrical work: Caesarian section has been performed 
eight times during the year, six times in this hospital and twice in the Presby- 
terian Women's Hospital. Of these, one was a case of central placenta praevia; and 
to anyone who has had the experience of dealing with this complication by the 
older methods, the relief from the strain of a case where one is certain to lose the 
child, and possibly the mother; and the satisfaction of a case, where a fine child 
is obtained, and the mother has an uncomplicated convalescence, make Caesarian 
section for this trouble the operation of choice. 

The remaining seven were all performed for contracted pelvis, four were for 
general contraction involving either an early induction with corresponding risk 
to the child, or Caesarian section. In one of these four a Caesarian section had al- 
ready been performed in America, and this was the second pregnancy. In a 
second case, the first child had been lost after a difficult forceps delivery in which 
the head was crushed, — possibly this was a craniotomy. In the third and fourth 
cases the patients were primiparae, came into the hands of the Department early 
in pregnancy, and the operation was definitely planned, and carried out as the 
measure of choice. 

The other three were cases of funnel pelvis. In each instance attempts had been 
made to deliver with forceps. In one case the condition had been examined by me 
myself, the upper measurements of the pelvis being over size, and the impossi- 
bility of getting a living child through the pelvis was not discovered till the reason 
for delay was investigated under an anesthetic. The other two were patients who 
had been some time in labor, and both operations were performed in the Douw 
Hospital by invitation of Dr. Hinkhouse. One, a primipara, had been examined 
outside by more than one person, the waters were broken, but fortunately she 
consented to a Caesarian, and both mother and child were saved. The other had 
been seen before labor came on, and had been warned and entreated to consent 
to a Caesarian section. Three children had already died during labor or immediate- 
ly after delivery and this was the fourth. She steadily refused until, after forceps 
having been tried, it was clear that no delivery could be accomplished without 
the destruction of the child, and then she consented. The child gasped only a few 
times. The mother, however, made a good recovery. One feature of the operation 



3 H PEKING UNION MEDICAL COLLEGE 

in the last two cases was the way in which the intestines had become distended, 
coming in front of the uterus when the abdomen was opened, and welling out of 
the wound, they could not be replaced until after the removal of the child and the 
turning out of the uterus; in fact in the last case the reduction of the intestines 
gave considerable trouble during the closing of the abdominal wall. With the ex- 
ception of the last-mentioned child, all the mothers and children did well. 

Sterilization was performed in only one case, that of the patient who already 
had had a Caesarian section. In this case the tubes were cut and tied and the ends 
buried. 

One case of uterine contraction ring has come under our care. The patient, a 
secundipara, went out in a riksha' as labor was coming on and was conscious of 
jolting. Whether this had anything to do with the malpresentation is doubtful. 
When first seen the head was riding over the brim, the cervix was three-fourths 
dilated with a large bag of waters, and there was no presentation to be felt. Dila- 
tation was allowed to proceed and when the membranes broke the os was fully 
dilated. A foot could then be felt high up, coming through a tight contraction ring. 
The patient was moved to the hospital and anesthetized. Pains had ceased com- 
pletely from the time of the breaking of the waters. Probably this was due to the 
altered polarity of the uterus as the first stage had been easy and the patient was 
not exhausted. On examination the condition was as follows: There was a tight 
contraction ring in the lower uterine segment, with an aperture about 4.5 cm. in 
diameter; through this protruded a foot and ankle, the toes of another foot, the 
fingers of a hand and a piece of cord, and on passing one's fingers through the 
ring, a part of the head was also felt; the child was alive. Circumstances made 
it impossible to perform Caesarian section, and so the next best procedure was 
adopted. Manual dilatation of the contraction ring was carried out as fully as 
possible and a leg brought down. The arms gave a little difficulty and the head 
still more, and it took about seven minutes to extract the head without tearing 
the parts. The child was resuscitated after a great deal of effort, but lived only 
about seven hours. At postmortem the principal feature was marked hemorrhage 
into and around the adrenals, a not infrequent occurrence in infants who have 
died in labor, or after they have been resuscitated with difficulty. Apparently 
the major number of these contraction rings are due to the cause which acted in 
this case: the fetal parts being prevented from coming down into the pelvis, the 
waters drain off into the lower uterine segment, and a contraction ring forms be- 
hind the bulk of the waters. They are very difficult cases to deal with. 

Only one case has given any trouble with postpartum hemorrhage. The patient 
was a quintipara with tuberculosis of the lungs and kala azar. She was an in- 
patient in the Presbyterian Hospital when five months pregnant, and at that 
time I seriously considered doing a rapid hysterectomy. But she was too ill for the 
operation. She then improved and went home. About the end of the eighth month 
she went into labor, and at about 3 a. m. was delivered of a living female child, 
with no excessive bleeding. I was at the hospital operating at about 10 a. m., when 
suddenly without any apparent cause she began to bleed so profusely that the 
only thing to do was to take her to the theater and pack the uterus. There was no 
further bleeding, but she had a stormy convalescence. After leaving the hospital 
she was better for a time, then the spleen again enlarged, ascites developed, and 
she died of asthenia. 



OBSTETRICS AND GYNECOLOGY 315 

Several cases of occipito-posterior presentation have been under observation. 
As is usual, the majority of these finally rectified themselves. 

Two of the cases, both primiparfe, call for special notice. In both for the last 
three months the presentation was persistently occipito-posterior. One of these 
finally rectified itself, but the child was still-born owing to a malformation which 
was found out only at autopsy. The left leaf of the diaphragm was absent, and the 
left lobe of the liver, the cecum, appendix, all the small intestine, spleen, and part 
of the stomach were on the left side of the chest, the left lung being a mere ru- 
diment. The placenta in this case was very adherent and had to be removed 
manually, but microscopically it was normal. 

In the second case the malpresentation persisted and the cervix dilated badly. 
When the mother began to show signs of exhaustion, dilatation was completed 
manually, and rotation of the head attempted. This could be partially accom- 
plished but the shoulders persistently refused to follow, apparently due to the 
position of the placenta, and finally I did internal version and delivered, the 
only difficulty being with one of the arms which had become extended. Convales- 
cence was afebrile in both of these cases. 

GYNECOLOGICAL CASES 

On the gynecological side the following cases may be of interest. Two cases of 
severe dysmenorrhcea, which was rendering life difficult for the patients, owing 
to the monthly pain and invaliding, were treated. One had a thorough dilatation 
performed, and has been practically relieved of her pain. There was also a pro- 
lapsed left ovary but this has given no trouble since the dilatation. 

The other case had also some retroposition, and had to spend two to three days 
in bed every month. Thorough dilatation was performed and then the abdomen 
was opened and a modified Gilliam operation used to bring the uterus into good 
position. The ovaries were very large and one showed a small follicular cyst. Half 
of this ovary was removed and both ovaries were drawn well up out of Douglas's 
pouch by a fine stitch passing through the broad ligament just below the tube. 
The result has been very satisfactory, menstruation having been regular and 
practically painless since that time. 

Two cases of abdominal tuberculosis have been treated. In the one there was a 
history of an attack of peritonitis some eight years previously and the patient 
was sterile. A tuberculous pyosalpinx was found on the right side, and the tube 
on the left side was sealed. The pyosalpinx on the right was removed and a plastic 
operation done on the left tube, but the probability is that as far as the sterility is 
concerned the operation will be unsuccessful. 

In the other case the provisional diagnosis before operation was tuberculous 
pyosalpinx. An appendix operation had previously been performed and the 
patient's father had died of intestinal tuberculosis. At the operation a large tuber- 
culous mass was found involving the cecum and base of the appendix and ad- 
herent to the back of the uterus. This tuberculous mass, consisting partly of 
bowel and glands, extended down to and involved the tissues of the posterior 
abdominal wall. It was freed from the uterus, a portion of omentum was inter- 
posed, and it was otherwise left alone. The patient made a good recovery, and 
gained fifteen pounds in weight during the next two months. The pain in the 



316 PEKING UNION MEDICAL COLLEGE 

iliac region, which had been very severe, disappeared after the operation. Of 
course the prognosis for such a case is not good, for even a resection of the cecum 
would not overcome the disease. However, a letter just received from this patient, 
who was sent home to America, states that she is in good health, acting as a 
librarian, that the mass is smaller and harder, and that the consultant is quite 
satisfied with her progress. 

Several cases of fibroid of the uterus have been treated during the year, among 
them the following are of interest: 

A woman, aged forty-eight, came to the clinic with a tumor up to the umbilicus 
which was causing dysuria and difficulty in defecation. This urinary trouble had 
existed a full year and there had been a period of chronic indigestion of which she 
complained more than of the tumor. It proved to be a large cervical fibroid (Figure i) 
and was removed by panhysterectomy. On microscopical examination the tumor 
in one part was found to be very cellular with many mitoses, and I predicted 
an early return of the trouble. The patient, however, made a very rapid recovery 
from the operation, spent the twenty-second day of convalescence at a Presidential 
reception and the twenty-third day at the Summer Palace. She remained well for 
about six months and then began suddenly to complain again of dysuria and 
difficulty with defecation. These difficulties rapidly increased, she was brought to 
Peking and found to have a large recurrent tumor in the pelvis, reaching well up 
towards the umbilicus. An exploratory operation was undertaken as obstruction 
was becoming serious, a large irremovable malignant growth was found, and it 
was clear that an inguinal colotomy would probably soon be blocked by the spread 
of the disease. A transversotomy was done and was a great success, relieving the 
obstruction and giving very little trouble. But a few days later first one leg became 
blue and swollen, then the other one followed suit. They became about twice nor- 
mal size, and greatly inconvenienced the patient, who suffered a good deal from 
pelvic pain for which morphia was freely given. After about a month she sat up 
on the bed pan one morning, lay back, became unconscious, and died in about 
fifteen minutes from pulmonary embolism. At the autopsy the clot was found to 
have been detached from one of the veins in the right groin; the growth which was 
frankly sarcomatous was invading a piece of the small bowel, and the ureters 
passed right through it. 

In this connection it may be of interest to note that we had one other case of 
pulmonary embolism. The woman had had a baby six weeks before, and had a 
slight mastitis but nothing of serious consequence. She went out into the yard and 
stooped to get some clothes, was seized with pain and difficulty in breathing, got 
into the house, became unconscious, with very rapid respiration, and died before 
I could get to her. 

A case of a small fibroid of the ovary which was causing much pain and in 
which the uterus also contained fibroids, was dealt with by panhysterectomy and 
did well. One very interesting case of fibroid polypus (Figure 2), was seen in con- 
sultation at the Presbyterian Women's Hospital and was operated upon there. 
There was a swelling filling the pelvis in a woman fifty-two years of age, causing 
some dysuria and difficulty in defecation. The os externum could be felt undilated 
high up behind and the feel of the mass in front was almost like a pregnancy. At 
the operation I intended to do a panhysterectomy but finally discovered that I was 




Figure i. Fibroid of cervix undergoing malignant change 




Figure i. Fibroid polypus which expanded anterior cervical wall 



OBSTETRICS AND GYNECOLOGY 317 

dealing with a fibroid polypus which had expanded the cervix, the anterior wall 
stretching much more than the posterior wall, and the os externum remaining 
undilated. She did well. 

Three cases were explored for sterility. In one tuberculosis of one tube was 
found with signs of old peritonitis. In another there was retroversion, but in this 
case the left tube, ovary, and round ligament were completely absent, the right 
ovary double normal size and burrowing into the broad ligament. A part of this 
ovary was resected. In the third case a persistent retroversion was corrected by 
means of a modified Gilliam operation and the uterus thoroughly dilated and 
curetted. 

Two most interesting cases of malformation were seen in consultation at the 
Presbyterian Women's Hospital. In one there was complete absence of the 
vagina with a uterus little under normal size and a blood cyst in the right ovary, 
the tube not being distended and there being no sign of a hematometra. 

The other case was that of a girl in a girl's school. Doubts had arisen about her 
sex and on putting her under an anesthetic the following condition was found. 
There was a well-marked penis with hypospadias. Beneath the urethral opening 
there was a small vagina containing a fruit stone. At the end of the vagina was a 
small lump evidently the rudiment of a uterus. Two glands could be felt near the 
internal abdominal rings almost certainly testes. The case was one of male 
pseudohermaphroditism, and the advice was given that the girl should change 
her sex and become a boy, or rather a young man, for she was seventeen years of 
age. The breasts were of the male type in this case, the voice husky, and the 
thyroid cartilage was prominent. 

Pathological material from a good many interesting cases has been received by 
the Department during the past year. Among other specimens a fibroid tumor 
of the ovary of unusual size and weight was received from Dr. Wylie of Paotingfu. 
It weighed twenty-seven pounds, was easily removed, and on microscopical 
section showed no signs of malignancy. 

Dr. Ford of Taiyuenfu sent us a portion of a tumor of the cervix and scrapings 
from the same uterus. The cervical tumor proved to be an adenoma but the en- 
dometrial scrapings were typical adeno-carcinoma. One case of our own deserves 
special mention. 

During the year four babies were lost at birth, or shortly after. I have already 
mentioned the cases of three of them: i. e., one still-born with malformation of the 
diaphragm, one which died seven hours after a very difficult breech delivery due 
to a uterine contraction ring, and one in a case of Caesarian section, attempts 
having been made to deliver with forceps and the case having been in labor for 
some time. The fourth was perhaps the most interesting of them all. The mother 
was an Austrian, a secundipara in the thirties. Her first child was born after a 
long labor, a 10-pound male child, but healthy, and it is still alive. During this 
pregnancy the mother who had become very stout, suffered a great deal, with 
much vomiting and wretchedness, especially from the third to the fifth months. 
The latter part of the pregnancy was not specially marked by illness, but she was 
not well. Labor came on to the day and was not specially prolonged or difficult. 
She delivered herself of an n^-pound female child, which came out blue but 
cried fairly well. Breathing was shallow but the lungs seemed to expand all over, 



3 i 8 PEKING UNION MEDICAL COLLEGE 

and oxygen and artificial respiration restored it to a fair color, but only for a short 
time. It became blue and after an hour or two it was clear we were losing ground, 
the intervals of good color becoming shorter and shorter. Dr. Douglas Gray was 
called in consultation and suggested bleeding, which was done without relief. The 
child died after four and one-half hours and a postmortem was obtained. The 
liver appeared large but was smooth and did not really weigh much over normal. 
There were no spirochetes to be found on microscopical examination. The spleen 
was about normal size, there was a small infarct, and it was adherent to the 
diaphragm. There was a little free fluid in the abdominal cavity. All the organs 
with the exception of the ovaries appeared normal on microscopical examination, 
and the foramen ovale and ductus arteriosus showed no abnormality. But the 
ovaries were hyperplastic to a remarkable degree, many cysts being present, and 
the ova had nearly disappeared (Figure 3). I shall be very pleased if any of you 
can throw light on the cause of this trouble. 

CONCLUSION 

In closing I present two cases for discussion as to the best method of treatment, 
I am sorry that it is impossible for me to show you the patients themselves, but 
on one Dr. Clark will operate tomorrow. 

The first case is that of a woman, aged twenty-five. She was in good health till 
she became pregnant. In the last three weeks of pregnancy she began to suffer 
from toxemia, slight trace of albumen, restlessness, and anemia. The pelvis 
showed a little general contraction. Nothing abnormal was noticed on examina- 
tion before labor. The head came down fairly well but there was a certain amount 
of primary uterine inertia and the labor was terminated by forceps, but as the 
head came down there appeared a swelling at the vulva about the size of a small 
hen's egg, which as labor progressed, protruded outside, and had to be very care- 
fully protected, and returned when forceps were applied and the child delivered. 
She had a long rest in bed owing to trouble with the breasts, but on rising im- 
mediately began to suffer from this swelling which appears at the vulva on 
straining. The uterus is retroposed and there is slight descent. Dr. Clark, who has 
kindly seen the patient with me, diagnoses the swelling as a vaginal cyst, and will 
operate on her tomorrow. 

The second case is that of a woman of thirty-two. She is a Swiss and of a ner- 
vous temperament. She was strong and well till her first confinement, which was 
badly managed and left her with a huge tear of the perineum, which was not 
sewed up. She was six weeks in bed. The child born on this occasion is alive and 
well, aged nine. In October, 191 2, she had a second pregnancy. She was in Switzer- 
land, was much worried at the time, had a great deal of vomiting, and abortion 
was induced at four months. In September, 1913, she was suffering from backache 
and probably also from prolapse, was in a weak nervous condition, and was per- 
suaded to have a fixation operation performed. Exactly what was done is not 
known, save that the tubes were cut, a centimeter of each removed, and the ends 
buried. After the operation she was better till a year later, when the pain in the 
back recurred and in addition there was constant burning pain in the region of 
the cervix. This has persisted ever since, she has been treated by local applications 
and douches many times without any permanent benefit. At present she is a 




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Figure 4. Uterus and ovaries of new-born fetus, normal, for comparison with 

Figure ,]. X2 



OBSTETRICS AND GYNECOLOGY 319 

neurotic woman, blood and urine normal, and she is in fair physical condition. 
She feels her inability to have children and deeply regrets having permitted the 
previous operation. The cervix is cleft to the left, edematous and chronically in- 
flamed. The uterus is bent acutely at the cervico-uterine angle, anteflexed, about 
normal size, and apparently fixed to the anterior abdominal wall. She is anxious 
that I should open the abdomen and try to reconstruct the tubes, and probably 
if this were successful and she had another child she would have much better 
health. Alternatively the cervix should be removed, but this of course will not 
relieve the mental attitude. Perhaps the best method would be to remove the 
cervix, at least the whole vaginal portion, and then explore from above, and be 
guided by what one found there as to the possibilities of reconstruction, but I 
have not fully made up my mind on the subject and shall be glad to hear your 
opinion on the matter. 



ECLAMPSIA AND ECLAMPSISM 
By 

Sir William J. Smyly, M. D. 

INTRODUCTION 

Eclampsia has been described as the disease of theories, but in the following 
paper I shall limit myself to what I believe to be well ascertained facts. 

Eclampsia is synonymous with convulsions, and puerperal eclampsia applies 
to convulsions of all kinds occurring in a woman before, during, or after labor. 
It is an unsatisfactory term because it includes cases which are essentially dif- 
ferent, and the same objection applies to toxemia, and to speak of eclampsia 
without convulsions comes very near a contradiction in terms. We must, there- 
fore, scrap our present nomenclature and discover some name which will include 
all those cases which are essentially similar, while excluding those which are not. 

Schmorl in 1893 published the results of his investigations into the pathological 
anatomy of puerperal eclampsia, confirmed by Lubarsh in 1895. The conditions 
described by Schmorl were chiefly characterised by thrombosis of the small blood 
vessels, necrosis of the cellular elements of the tissues, and hemorrhages. These 
conditions were found by him in all the autopsies which he made, upon nearly 
one hundred women who had died from eclampsia, and were present in the kid- 
neys, liver, brain, heart, lungs, and indeed in every part of the body; and, as they 
were not found to the same extent in any other disease, he felt himself justified in 
concluding that here was a disease peculiar to lying-in women, and their new 
born children, and characterised by certain definite anatomical conditions which 
were considered by him to be essential to and characteristic of the disease. There- 
fore, when these conditions were present, the case was one of eclampsia; when 
they were absent, it was not. The blood in eclamptic women is thicker than 
normal, of higher specific gravity, and contains, as Kollmann discovered in 1897, 
an abnormal amount of fibrin and, as Schmorl pointed out, a special tendency to 
coagulate in the blood vessels. The anatomical changes found throughout the 
body after death, by him and by Lubarsh, appear to have been caused chiefly by 
this coagulation in the small vessels, and the consequent necrosis of and hemor- 
rhages into the tissues supplied by them. In a subsequent paper he described the 
postmortem examination of some cases which had died in coma without any 
convulsions, in which the same pathological conditions were found; therefore 
they were cases of eclampsia, though without convulsions. 

It has been known for a long time that, as a rule, convulsions are preceded by a 
complex of symptoms which we have been accustomed to call the pre-eclamptic 
state. Most of these cases, however, do not have convulsions, but whether they 
do or not, the disease is evidently the same. It has already been stated that one 
of the essential characteristics of this disease is hemorrhage, most commonly 
minute petechial hemorrhages, but occasionally very extensive, serious, and even 
fatal in amount. Anyone who has had much experience with eclampsia must have 
met with such cases, where the bleeding occurred into the brain, into the eye, 

320 



OBSTETRICS AND GYNECOLOGY 321 

into the peritoneal cavity, or under the skin; but it is only recently that our 
attention has been called to the fact that intra-uterine hemorrhage also may be 
caused in the same way. Since then all these conditions, namely, pre-eclamptic 
toxemia, eclampsia, eclampsia without convulsions, and accidental hemorrhage 
are generally symptomatic of one and the same disease, it is desirable that they 
should be grouped under one name, and I think the suggestion made by Dr. Bar 
of Paris an excellent one that, while retaining the term eclampsia for those cases 
in which there are convulsions, we should employ the word eclampsism for those 
in which there are none. 

TREATMENT OF ECLAMPSISM 

In the treatment of eclampsism obstetricians have been influenced chiefly by 
their views as to whether its causation is ovular or maternal. Those who consider 
that the disease is due to the ovum maintain that its removal, at the earliest 
possible moment, is the only rational procedure; while those who look upon the 
disease as the result of faulty metabolism on the part of the mother, direct their 
efforts towards combating her toxemic condition. The extreme members of the 
former group resort to Caesarian section in every case after a single convulsion; 
the extremists of the other group leave the delivery altogether to nature. Neither 
of these methods has fulfilled the expectations of its advocates. I think there can 
be no doubt that both the ovum and the mother participate in the production of 
the eclamptic condition, the fact that it occurs only in connection with pregnancy 
being sufficient proof of the former, and the good results obtained by limiting the 
mother's food the latter. We know that in digestion a very important part is 
played by the blood, that this digestive power is far in excess of normal require- 
ments; but that this power is not unlimited we learn by experience when we eat 
too much and do too little. During pregnancy the maternal blood has the added 
task of dealing with material poured into it from the ovum, and the occurrence or 
not of toxemic symptoms depends upon whether it is equal to that task. Some 
years ago Doctor Tweedy, when master of the Rotunda, formulated a system of 
treatment which obstetricians in Dublin and in other places have since adopted 
with remarkable success, the most important feature of which is the restriction of 
the diet of the patient to water, or in other words starvation. A remarkable 
confirmation of the advantages of this method of treatment has been furnished 
by what has occurred in Germany during the late war where, consequent upon 
the lack of food there, due to the blockade, the proportion of cases of eclampsia 
to the births sank, according to Warnekros and Schulein, to one half, and was 
estimated by Ruge at one third the normal pre-war rate; and further that the 
cases were of a milder type, as shown by the reduction of the death-rate from 
10 per cent to 8 per cent. 

In describing the treatment of eclampsism in the Rotunda Hospital I shall do 
so under three divisions: 

1. Treatment of pre-eclamptic toxemia. 

1. Treatment of eclampsia. 

3. Treatment of accidental hemorrhage. 

In pre-eclamptic toxemia treatment should commence at the earliest moment 
possible, hence the importance of prenatal clinics. The patient should be put to 



322 PEKING UNION MEDICAL COLLEGE 

bed and given water only, with some laxative medicine. If improvement follows, 
some light food, such as milk, may be given, noting carefully the result; if she 
continues to improve she may have more food, but if a relapse follows any addi- 
tion, then labor must be induced. The benefits to eclamptics which have been 
claimed for a milk diet are only comparative. It is only better than other foods. 

When a patient first comes under treatment after one or more convulsions she is 
given 0.5 grain morphia hypodermically. Her stomach and rectum are thoroughly 
washed out by means of a stomach tube until the fluid returns quite colorless, 
requiring as a rule several gallons of water; about half an ounce of Epsom salts is 
passed into the stomach through the tube before it is withdrawn. If the patient is 
conscious, she is encouraged to drink as much water, to which bicarbonate of soda 
is added, as she will take. If unconscious it is infused into her cellular tissue, under 
the breasts or elsewhere. As regards complications, precautions must of course be 
taken to prevent the patient from biting her tongue, or otherwise injuring herself. 
But a common cause of death, and one easily prevented, arises from allowing an 
unconscious patient to lie upon her back. In such cases an enormous amount of 
mucus is likely to collect in the nasopharynx, and in that position will be drawn 
into the lungs, drowning her in her own secretion, or causing a septic pneumonia 
which subsequently proves fatal. It is, therefore, of very great importance that 
these patients should be kept in a semiprone position; and should any symptom 
of impeded respiration occur, her head should be drawn over the side of the bed, 
well down to the floor, when usually a large quantity of mucus pours out of the 
mouth and nostrils and respiration is restored. We never sweat our patients now, 
as we believe that it does more harm than good. Chlorides in any form are inju- 
rious, and therefore we employ the bicarbonate instead of the chloride of sodium 
for infusions, and chloroform is employed under exceptional circumstances only. 

As regards the delivery of the patient, it is completed as quickly as the special 
circumstances of each case will permit, without increasing the risk to the patient. 
Accouchement by force, by which I understand version and extraction through an 
undilated cervix, does not fulfill these conditions, because it materially increases 
the danger to the mother, and should be abandoned. 

The treatment of concealed accidental hemorrhage by abdominal section and 
hysterectomy, was originated with Dr. William Bagot, now of Denver, Colorado, 
when he was my assistant in the Rotunda Hospital, and was successfully carried 
out by him upon a patient in the Extern Maternity. But it was several years be- 
fore any other operator ventured to follow his example; and when in 1910, Dr. 
Amand Routh published a report upon 1,280 cases of Caesarian section collected 
from obstetricians living in Great Britain and Ireland, only three had been per- 
formed on account of accidental hemorrhage. Since then, however, it has been re- 
sorted to more frequently, and is now, I believe, generally recognized as advisable, 
at least in those cases in which the patien t is not in labor and the hemorrhage is con- 
cealed. Since the introduction of this line of treatment, which in my opinion marks 
a distinct epoch in obstetric history, we have learned that the actual conditions 
are very different from what we had imagined them to be. We knew, of course, 
that the placenta was detached, and that the uterus was distended with blood, 
and assumed that, because this effused blood was not expelled, there must have 
been a weakening or paralysis of its. walls, but its true cause had not been deter- 



OBSTETRICS AND GYNECOLOGY 323 

mined. Now we know that the blood is poured, not into the uterine cavity alone, 
but also into its muscular wall, which is suffused with blood, separating and no 
doubt injuring its muscle cells. This accounts sufficiently, not only for the yield- 
ing of the walls to the pressure of the blood, but also for the extreme difficulty 
which has sometimes been experienced in controlling postpartum hemorrhage. 
In many of the reported cases there was hemorrhage also into the pelvic cellular 
tissue, especially between the folds of the broad ligaments, and into the peritoneal 
cavity. In two cases, reported by Whitridge Williams in 191 5, in which the uterus 
had to be removed, the microscopic examination showed that the hemorrhage 
had spread apart the individual muscle fibers and bands, and in places was asso- 
ciated with considerable edema, and that it apparently was not connected with 
the larger vessels. Section through the placental site showed similar changes in the 
muscular wall; but the decidual were normal, except for small hemorrhagic areas. 
In this region many of the larger veins were almost completely filled with large 
thrombi. The large arteries were normal, but many of the smaller ones presented 
changes in the intima, and in many places defects were observable in it. The 
principal pathological changes presented, therefore, were thrombosis of the veins, 
necrosis of the intima of the small arteries, and hemorrhages into, and edema of 
the uterine walls. This remarkable condition of the uterus has, during the past 
few years, been frequently noted by other observers, in connection with accidental 
hemorrhage, and at a single meeting of the Obstetrical Section of the Royal 
Society of Medicine in London, in November, 1 9 1 6, no fewer than eight cases were 
reported. This condition has been described by Couvelaire as uteroplacental 
apoplexy, and although he considers it to be a constant feature in accidental 
hemorrhage, yet he regarded it as merely the result of overdistention of the uterus. 
That in my opinion is a most important question, because if the effusion of blood 
into the muscular tissue were merely the result of overdistension, then its con- 
nection with eclampsia is not so obvious as I suppose it to be. But if, on the other 
hand, it can be proved that this condition is not caused by overdistension, that it 
occurs only in patients with symptoms of toxemia, and that the anatomical con- 
ditions associated with it closely resemble those which cause hemorrhages in other 
parts of the body in eclampsia, then it would seem to me a justifiable conclusion 
that it is due to the same cause. As regards the theory that the remarkable con- 
dition of the uterus is merely the result of its overdistension, I may refer to some 
experiments carried out by Dr. Arthur H. Morse in Yale University Medical 
School (1). He was prompted to make those experiments by two cases of concealed 
accidental hemorrhage, in which he was struck by the resemblance between the 
conditions there found and those which are met with in cases of ovarian tumors 
with twisted pedicles. His first endeavor was to discover whether sudden over- 
distension could, as had been affirmed, produce such phenomena. With that ob- 
ject he exposed, by abdominal section, the uterus of a pregnant bitch, inserted a 
canula into it, and injected saline solution until it was distended almost to burst- 
ing. No ill-effects, excepting abortion, followed; and when the abdomen was again 
opened, after forty-eight hours, the previously distended horn was found to be 
entirely normal, without any sign of injury. That experiment showed that even 
extreme and acute increase in intra-uterine pressure did not cause extravasation 
of blood into the myometrium. Some time after he made a further series of ex- 



324 PEKING UNION MEDICAL COLLEGE 

periments upon rabbits, with a view to ascertaining what the results of venous 
obstruction in a pregnant uterus would be. He discovered that, when all the veins 
returning blood from a pregnant horn had been ligated, it became deeply cyanosed 
and distended, at first functionating, but ultimately firm, tense, and resistant to 
pressure. After from two to four hours it was found enlarged to about twice its 
former size, and was quiescent, muscular action having ceased. When incised, the 
uterine cavity was found filled with blood, which surrounded the unruptured fetal 
sacs; the placentae were partially or completely separated from their attachment 
and minute extravasations of blood were visible in the myometrium. The micro- 
scope showed numerous extravasations in the decidua and into the uterine wall, as 
well as dissociation of the muscle fibers; in fact in every particular an exact re- 
production of the conditions found in cases of accidental hemorrhage. 

CASES TREATED AT ROTUNDA HOSPITAL 

The following cases, of which I shall give a very brief summary, illustrate very 
clearly the connection between eclampsism and accidental hemorrhage. 

Case i. This patient was admitted to the Rotunda Hospital in 191 5 under Dr. 
Tweedy's care. She was pregnant about seven months. Her face, legs, and thighs 
were edematous. She complained of intense headache, dimness of vision, and 
vomiting, secreted very little urine, which contained numerous tube-casts and 
became almost solid when boiled. Her blood pressure was very high, — a typical 
example of the pre-eclamptic state. She was restricted to water and the usual treat- 
ment was adopted. She improved for a time but a week later suddenly complained 
of violent abdominal pain; a bloody discharge, which gradually increased to a con- 
siderable hemorrhage, escaped from the vulva; it was apparently controlled by a 
vaginal plug, but her general condition grew steadily worse. The face became 
blanched and cold, the features pinched, the pulse more rapid and weaker. The 
diagnosis was internal hemorrhage. On opening the abdomen a considerable quan- 
tity of free blood was found in its cavity, the source of which was discovered in 
the right broad ligament, and was controlled by a ligature thrown around the 
ovarian vessels on that side. The uterus also contained a large quantity of blood, 
the placenta was completely detached, and the fetus dead. The operation was 
completed without removing the uterus which contracted well. There was no 
postpartum hemorrhage, and she made a good recovery. 

Case 2. I was asked to see this woman in November of the same year (191 5) by 
her family physician who had diagnosed the case ten days before as one of toxemia, 
and had restricted her to a milk diet, but no improvement had resulted. When I 
saw her there was anasarca, with puffy face, and swollen eyelids; the urine was 
scanty and contained a large quantity of albumen. I stopped the milk and gave 
nothing but water, under which treatment she improved so much that at the end 
of a week she could take milk; and I discontinued my visits. Ten days later, how- 
ever, she was seized with violent abdominal pain and fainted. On my arrival I 
found her in a critical condition with all the symptoms of severe internal hemor- 
rhage; the uterus was firm and hard, and no fetal parts could be felt. Fortunately 
labor came on immediately and after a few pains a dead infant, the placenta, and 
a large quantity of blood and clots, were all expelled together. She was very col- 
lapsed for a time but made a good recovery. 



OBSTETRICS AND GYNECOLOGY 325 

Case j. This patient was admitted to the Rotunda Hospital under my care in 
September, 1917. Her two previous pregnancies had terminated normally at full 
time. On this occasion she had noticed nothing abnormal until the evening previ- 
ous to her admission when she was seized with violent abdominal pain and a 
feeling of distension, and she noticed an increase in the size of her abdomen. 
When admitted to the hospital she was in a collapsed condition, blanched, cold, 
temperature 95. 4 F., pulse hardly to be felt. Uterus very hard and tender, no 
fetal parts could be felt. There was no external hemorrhage, urine scanty, loaded 
with albumen casts in large numbers and some blood-cells. When the abdomen 
was opened the uterus presented a remarkable appearance; it was dark, almost 
blue in color, with blood extravasations in patches over its surface, the peritoneal 
covering being in places raised in large blebs filled with blood, one of which upon 
the posterior surface had burst, the rent being about an inch long, and there was 
free blood in the peritoneal cavity. When cut through, the uterine wall showed 
blood extravasations throughout, the cavity was filled with blood, the placenta 
completely detached, and the child, of course, dead. After the uterus had been 
emptied and the wound closed, it contracted well with pituitrin, and therefore I 
did not remove it. 

Case 4. A woman, aged thirty-nine, nonipara; thirty-six weeks pregnant. Was 
admitted to the Rotunda Hospital on December 7, 1917. 

Twelve years previously, her first pregnancy terminated prematurely at the 
eighth month, in consequence of eclampsia, preceded by headaches and disordered 
vision, and ever since, the sight in her left eye had been impaired; she was uncon- 
scious for a week and the child was still-born. The four succeeding pregnancies 
were normal, the children living. But after the birth of the last, four and a half 
years previously, she did not make a satisfactory convalescence; had three abor- 
tions subsequently, and was curetted in 19 16. 

On admission she said she had been ill for about three weeks, suffering from 
headaches and impaired vision. There was a large ecchymosis on the left buttock. 
The urine was scanty, and of a bright red color, and contained a large quantity of 
blood and tube-casts. The child could be easily palpated, presenting the head in 
the first position. The diagnosis was pre-eclamptic toxemia, and she was treated 
in the routine manner, introduced by Dr. Tweedy, getting nothing by the mouth 
but sodium bicarbonate and water. She got little sleep in spite of a hypodermic 
injection of morphine, and the total quantity of urine passed in the first twenty- 
four hours was 20 ounces. The blood-pressure was 260 mm. The following day 
there was no improvement, and some twitching in the muscles of her arms. She 
was given 0.5 grain of morphine hypodermically. During the following days there 
was no marked change in her condition; but on the sixth day she seemed to be 
rather better, and had passed 31 ounces of urine during the previous twenty-four 
hours, but in quality it was the same as upon admission, and the blood-pressure 
was still 250 mm. 

Considering that she had been restricted to soda and water for five days, since 
her admission to the hospital, and that she said that she had eaten nothing for 
two days before then, I thought it advisable to give her some nourishment. 
Accordingly, at 12.30 p. m. she took four ounces of milk with an equal quantity of 
barley-water. At ten minutes past one she complained of a violent pain in her 



3*6 PEKING UNION MEDICAL COLLEGE 

abdomen, and said that she could see nothing. She looked pale and collapsed; her 
skin felt cold, clammy, and bathed in perspiration; her temperature was below 
normal, and there was a little reddish discharge from the vulva. Her abdomen 
was evidently larger, the uterus swollen, hard, and tender, and the fetus was no 
longer palpable. Her condition, indeed, appeared desperate, but being persuaded 
that her life could be saved in no other way, I determined to operate immediately. 
The abdomen having been opened, the uterus presented the same remarkable 
appearance which I have already described, being much distended, of a dark, 
bluish purple color, with numerous patches of ecchymosis on its surface. The 
wall when cut through showed blood extravasated throughout its substance. 
The placenta was completely detached, the cavity full of blood and clots, and the 
fetus dead. To save time, which was of vital importance, I closed the uterine 
incision with a running suture of Van Horn's catgut, otherwise the operation was 
carried out in the usual manner. Towards its close the patient appeared to be dead, 
but gradually revived, and was removed to bed. She made a good recovery, 
though, owing to her toxemic condition, she was still restricted to soda and 
water for the three succeeding days. Her urine improved rapidly both in quantity 
and quality, so that on the fourth day it was normal in color and free from 
albumen. 

I believe that a consideration of these cases, together with others published by 
other obstetricians, is sufficient to prove that many, if not most of the cases of 
severe accidental hemorrhage are due to conditions closely allied to, if not identi- 
cal with eclampsism. Although in all the cases, one operated upon by Dr. Tweedy, 
and two by myself, the uterus was not removed, yet from a consideration of the 
cases published by others, I have no doubt that in some the uterus will not 
contract, and its removal is necessary to save life. 

BIBLIOGRAPHY 
I. Morse, A. H., Surg., Gynec. and Obst., 1918, xxvi, 133. 



MATERNITY FAMINE RELIEF 

By 

Jean I. Dow, M. D. 

INTRODUCTION 

In normal times midwifery has occupied a small place on the program of the 
Women's Hospital at Changteh. One feels ashamed to make this confession, for 
it would be a platitude to say that a hospital conducted by women could find no 
finer scope and could exercise no more useful function, in the physical realm, than 
by leading the way in the liberation of fellow-women from the meddlesome 
though well-meant atrocities of the self-taught midwife of Inland China. The 
city in a suburb of which we are situated is conservative, and on the other hand 
the limitation of a one-doctor staff during a period of fifteen years discouraged 
the uncertainties of out-practice so that our record of only a few obstetric cases 
each year has brought us little fame in the eyes of the Chinese community. But 
one cannot conduct a general clinic for women and children without receiving 
convincing demonstration of the urgent call for preventive gynecology, not to 
speak of saving life and preventing cruelty. 

When other forces were lining up last autumn to face the task of life-saving, 
while we were faced with vanishing clinics and sparsely occupied wards, we began 
to cast about with anxiety for a fitting part to play, a place from which we might 
reach not those within the radius of church connection who could be helped by 
other routes, or those who by proximity to a distributing center might gain notice 
through personal appeal, but some of those on the outer rim too far away to be 
anybody but one of the crowd. Then some unknown person also in search of pos- 
sible avenues of relief, conceived the thought of an allowance for the nursing 
mother. The press mentioned it, and the solution of our problem came into focus: 
a free maternity service with a subsequent monthly allowance for mother and 
child to the end of the famine period. 

PLAN FOR RELIEF 

The plan was approved by the local committee, the maximum grant fixed at 
#2.50 per month, conditional upon presentation before the inspector of both 
mother and child wearing their identification mark, the inspector to be made re- 
sponsible for the bona fide character of the applicant's claim. For purposes of 
general investigation and distribution the local Christian Chinese Foreign Famine 
Relief Society had already put into operation a card system for use through in- 
vestigators selected from the elders, deacons, evangelists, or church members in 
the various areas. These men performed the same service for us. Proclamations 
were issued announcing the terms of the offer and the name and address of the 
inspector in each locality to whom application should be made. Tickets bore the 
hospital seal and were made out in sets of three. The applicant received one — her 
admission slip — on which the inspector filled in number, name, age, residence, 
family head, occupation, and guarantor. On the opposite face were columns for 
recording month by month the amounts actually paid. The inspector filed a larger 

3V 



328 PEKING UNION MEDICAL COLLEGE 

ticket giving the same facts with additional columns for data to be transcribed 
from the hospital copy, such as dates of admission, confinement, discharge, sex of 
child, and amount of grant. The hospital copy recorded, in addition, notes on 
special circumstances of the patient. 

Misappropriation by the family was guarded against by the regulation that un- 
less the child was presented for inspection the allowance would be withdrawn. In 
actual practice, however, it was found that where the death of the child was re- 
ported, the family frequently was in sore straits. Help was continued, therefore, at 
a minimum rate of $1.00 per month, and where a motherless infant was adopted, 
the full amount was given. If the mother engaged in a self-supporting family as 
wet-nurse, her name was deleted from the pay-list. In some instances there were 
blind or dependent parents, in others sick husbands, and in most others little chil- 
dren. In view of the following notes from the records, one feels little surprise that 
out of a total of 489 births under the scheme, twenty-five babies and five mothers 
succumbed at home. 

No. 192. Husband, two children, and self fled to Shansi. Sold their quilts to 
raise money to come home. Have sold even the wheel-barrow (the sole equipment 
of the bread winner). Mother-in-law ill, unable to rise for want of food. 

No. 222. Widow with three children. Family left home. Husband for a time 
found occasional work in the South Suburb. Finally lived in Beggar's Refuge. 
Little girl died there. Husband died there ten days ago. Two boys in ragged 
clothes, one looks ill. Child born on the road, east of Mission Compound gate. 

No. 150. Mother and baby normal when discharged. Six weeks later appeared 
in outclinic, baby emaciated, mother unable to walk without assistance. Boy of 
five, characteristic famine appearance. Husband's brother appropriated part of 
the wife's grant to pay debt. Husband had been ill and took part for travelling 
expenses. Woman and baby readmitted, child of five fed from hospital kitchen. 
Baby died. Mother redischarged after a fortnight. Full allowance continued. 
Money again confiscated to pay debts. Mother died of insufficient nourishment. 

FINANCES AND SUPPLIES 

Anxiety regarding finances was removed at the outset by an immediate appro- 
priation of $4,500 from the Chinese Foreign Famine Relief Society of Shanghai, 
a further $1,000 following later, with the addition of J700 from other sources, 
and the question of equipment was greatly simplified by the timely grant from the 
American Red Cross of goods which had just been opened up. These were rolls of 
flannelette and flannelette blanketing, thousands of yards of gauze, three cases 
of large pads, besides layettes, babies' blankets, adhesive plaster, and many other 
nursery requisites, which, inasmuch as we had not sent in a requisition, created a 
comfortable sense of the presence of a Co-operator behind the scenes who had 
planned in advance. 

When the day of discharge of the first cases arrived, it was found that families 
had made, and could make, no provision for even the irreducible minimum of 
clothing for the new members. It was unthinkable with one fell stroke to cut off a 
baby of seven or eight days from comfort and warmth and turn it adrift. Material 
was therefore given to each waiting mother with a promise that the completed 
garments would be hers against going home day. And presently the Shanghai 



OBSTETRICS AND GYNECOLOGY 329 

Women's Famine Relief Committee, as well as interested Chinese and foreign 
friends in Manchuria and Hangchow came grandly to the rescue with plenty of 
padded clothing and comforters, so that every child had a going away suit, cap, 
and comforter, while hundreds of suits too large for small babies were passed on 
for distribution to older children. Mothers with thin or ragged garments were 
fitted out and comforters were given to those in distress. 

HELP TO WAITING CASES 

In order to check, too early arrival, no provision for food was promised during 
the antepartum period. Hostel space and facilities for cooking were provided. 
When spring opened, patients were permitted as a special privilege to help them- 
selves to alfalfa shoots from the mission grounds as a substitute for vegetables 
at prohibitive prices. Some earned their food by sewing, and always a certain 
number helped in the laundry, partly as a means of subsistence and partly for 
exercise. Numbers went regularly to the public food kitchen in the East Suburb. 
Exceptions of course were made from the first, for instance, a blind woman whose 
husband was a non-provider, was fed for over two months. One of the first cases, 
whose son had been sold for $5.00, proceeds already spent, and whose sister-in- 
law had starved, leaving an infant of a few days to be buried alive in the mother's 
grave, was sent to us to save her from a similar fate. This woman was so ema- 
ciated that she was put to bed for a few days and was then supplied with food for 
over two months. 

During the earlier months the nutrition of the babies at birth was so good that 
we wondered if homes were suffering as great privation as had been supposed, but 
in the later months when a large proportion of the pregnant period had been 
passed under unfavorable conditions, it became obvious that infants were being 
born with a handicap so serious that the object of the scheme might after all be 
defeated. It was then decided that a sufficient daily portion of grain or flour be 
allotted to every patient in the antepartum hostel. On the whole we were probably 
overcareful not to overhelp, as a considerable number were admitted and exam- 
ined, who never passed through the delivery room, presumably concluding that 
they would take a chance at home. 

SOCIAL CLASS AND HOME CIRCUMSTANCES 

The social class and home circumstances of patients are shown in the follow- 
ing summary: 

Husbands 

per cent 

Laborers without land, including scavengers . 52.4 

Small land owners; amount 1 to 20 mows (1 mow=| acre) 12. 1 

Small business men; selling peanuts, brooms, cakes . .... 10.89 
Non-providers; e.g., opium users, gamblers, beggars, persons mentally 

deficient, blind, dumb 6.0 

Artisans . 4-9 

Professional; three teachers, one medicine man .... 0.94 

Soldiers; three recently enlisted 0.70 

Dead; one shot, one ill, three starved, one cholera .... ... 1.89 



33o PEKING UNION MEDICAL COLLEGE 

Sample Cases 

Landowner. Six in family — husband, four children, and self. One mow land, 
irrigated, not sufficient for a family of six, at present prices. Non-Christian. 

Artisan (Harness-Maker). Six in family — mother- and father-in-law, husband, 
and two children. Husband, no work, gone to Shansi. Word received that the 
grandmother of ninety-four years had been shot dead, one boy shot but not 
fatally, mother-in-law shot in the arm. House burned. 

Laborer's wife told this story. There were two brothers in the family. They 
lived in a small house, partitioned by a wall reaching only part way to the ceiling. 
Every salable article had been sold. On the other side of the partition her sister- 
in-law had recently been delivered. The only dressings used were rags and earth, 
and these were never changed. Mother and baby died. 

Fate of Children 

Information on this subject is confessedly incomplete and incidental. Of 1,691 
births reported in the antepartum room, 790 children were still living, a mortality 
of $3 per cent. Such causes of death as were investigated invariably fell under the 
head of disease, the most frequent single cause being that which is popularly 
known in Honan as " Chi feng," and in no case did the mother's manner excite 
suspicion of wilful neglect. 

Typical History 
Liu, aged thirty-seven. 
Births 

1. Difficult labor, mutilated. 

2. Died second day. 

3. Still-birth (?). 

4. Died sixth day (Chi feng). 

5. Died, one day's illness, abdominal cramps. 

6. Cried, but died shortly. 

7. Did not outlive first month. 

8. Living. 

9. Died at one year. Infectious disease (eruptive fever). 

Record of Children Lost to Families 

Given away: Five boys, and two girls sent to mother-in-law's home. 

Two unclassified. 
Sold: Two boys and four girls. (One boy returned, not wanted because 

he was deaf.) 

One unclassified. 
Starved: Two boys and four girls. 

Circumstances under Which the Children Were Disposed of 
No. go. Two girls sold for $10.00 and $6.00. Family exceedingly poor, children 

no clothes. Four adults and four children left. Would have died without the 

money received for these girls. 

No. 123. Gave away two youngest boys for lack of food. 



OBSTETRICS AND GYNECOLOGY 331 

No. 149. Sold eldest son, brought back because he was found to be deaf. 
Youngest very emaciated. Husband mentally deficient. 

No. {Not Recorded). Six children in family. Youngest a boy of two years given 
away because there was nothing to eat, and he was too young to beg. Grandfather 
died of starvation while mother was in hospital. 

No. 201. Sold one daughter. No home. Husband and four children. 

No. 410. Husband wanted to sell girl of two years. Wife not willing. Husband 
left mother and child to beg, and left home. 

No. §82. Sent daughter of eight years to mother-in-law. Sold daughter of five 
years to child dealer. Would not have sold her if they had had any other means 
of subsistence. Did not know danger of ultimate destination. 

No. 629. Daughter forced on mother-in-law rather than sell. 

No. 658. Widow maintaining orphan niece in addition to her own two children, 
though husband died of starvation. 

A^o. J23. Two nieces included in family. 

(The impression left on the mind was that either girls or boys were parted 
with only as a last resort and that mothers were not informed of the magnitude 
of the white slave menace.) 

PHYSIQUE OF MOTHERS 

i. All women had moderately bound feet and wore bandages if they could 
afford them. With few exceptions the journey was made on foot, even to distances 
of 30 or 35 miles. It was not to be wondered at that nineteen births occurred on 
the way, one mother having been reduced to sundering the cord with her teeth. 
One, more fortunate, arrived safely, but armed for emergency with a pair of 
scissors. 

1. To say that we observed no abnormality of the pelvis and at the same time 
to admit that the pelvimeter was not used as a routine part of the antepartum 
examination may be to court criticism. It is safer to say that no case occurred of 
dystocia from disproportion between pelvic and fetal measurements. Internal, 
antepartum examination was made as a routine. We were pressed for time, and 
unless there arose a suspicion of contraction, as existed in one case only, the use 
of the pelvimeter was dispensed with. In this case the external measurements 
were slightly below the average but labor presented no difficulty. 

3. No case of venereal disease was noted. In our experience the classes that 
supply most of the material for this clinic are wives of soldiers, railway employees, 
merchants, and coolies, who are often absent from home. In the above list these 
classes are conspicuously absent. 

4. The nipples were well formed and hardy. No case of cracked nipple occurred 
and no mastitis. 

5. There were no cases of toxemia. 

LABOR 

Labor was undoubtedly marked by less suffering than is experienced by 
Western women of the working class. As a rule in multipara? the second stage was 
brief, sometimes almost to vanishing point. Perineal tissues offered less resistance 
than in the average Western patient and rupture of the membranes was followed 



33* PEKING UNION MEDICAL COLLEGE 

rapidly, if not preceded, by presentation at the outlet. Of thirty-two primiparae 
the average age was twenty-one. Seventy-two per cent were twenty-two or under, 
50 per cent were twenty or under; the two youngest were seventeen, the oldest 
was thirty-three. Slight perineal laceration occurred in 1 per cent of all cases and 
in one or two of these it might have been prevented by more liberal use of the 
anesthetic. 

The strength and frequency of the contractions was strikingly influenced by 
posture. So often did a marked slowing up follow assumption of the horizontal 
position that it became a habit when the patient was placed on the table to ob- 
serve the effect before draping so that if expedient she could be raised to a sitting 
posture. 

The value of a bowl of hot food in muscular insufficiency was amply demon- 
strated. 

PRESENTATIONS 

Vertex (occipito-anterior) 413 

Vertex (occipito-posterior) 4 

Face 2 

Breech 4 

Foot . 4 

Shoulder . 1 

Hand . 1 

Total . . .... ... 429 

In occipito-posterior and face presentations delivery was spontaneous. In the 
majority of the breech and foot cases assistance was given with the after-coming 
head by the "jaw and shoulder traction " method, while resuscitation of the child 
when necessary was effected by alternate immersion in hot and cold water. 

In the shoulder and hand cases internal padolic version was performed. 

There were two cases of multiple pregnancy in the series but one pair was born 
before the mother could leave home. In our case one child presented by the occi- 
put, the other by the breech. 

There were two still-births, one due to prolapse of the cord; the other, cause 
unknown. 

Adherent placenta, of which there were four cases, and retained membranes 
were removed without known exception, normal convalescence following. 

Postpartum relaxation yielded to massage and pituitrin or ernutin. 

PUERPERIUM 

The Mother. Two deaths occurred from sepsis. Whether the source of infection 
lay in faulty technique or in internal manipulation by the patient herself during 
the first stage of labor we have no means of knowing. One woman confessed to 
having palpated the descending occiput and it is a fact that self-manipulation for 
purposes of investigation is not uncommon, but for the result in these two fatal 
cases we are safer to carry the odium ourselves. 

Procidentia was observed in one whose child was about to be thrown away 
when the hospital's offer of help reached her. Walked in .10 miles. 



OBSTETRICS AND GYNECOLOGY 33 3 

'The Child. In all, seven babies died during the puerperium, including four very 
small at birth, one premature, and one having a widely separated cleft palate. 
(Cause of premature labor, a blow from a man who observed her stealing his 
vegetables.) We had not the staff nor equipment nor space to set aside for a large 
nursery and in any case separation from the mother would almost certainly have 
created undesirable suspicion regarding identity and treatment. But the system 
cost us two babies accidentally smothered. 

One hundred and forty-eight returned for vaccination. 

RELAPSING FEVER 

Four cases were met within the maternity cervix: 

Case I. Refugee to Chengchow by train. On return trip birth took place at 
Changte Railway Station. Temperature on admission 104.4° F- Blood examina- 
tion positive. 

Case 2. Child born on main street, Changteh City, near an official home. Mother 
given 120 coppers and a bowl of flour and sent in 'riksha to the hospital. Tem- 
perature on admission 103. 6° F. Person swarming with lice. Clothed in filthy 
rags which were carried out on the end of a pole and burned. Patient was bathed 
and kerosened. Blood examination showed overwhelming numbers of spirochetes. 

Case J. Had been living in Beggar's Refuge. Developed attack in convalescent 
ward. Clothes burned (?) or disinfected. Blood examination positive. 

Case 4. Had been in waiting ward eleven days under no restrictions as to 
going out. Did not complain until the onset of labor when temperature was 103° F. 
Her stool was examined and ova of Ascaris lumbricoides found. Passed two 
Ascaris worms and temperature fell to normal. Blood examination omitted by 
default. On ninth day temperature began to rise. Blood examination showed 
the Spirillum. 

Of the modification of salvarsan sold by Allen and Hanburys, Limited, we used 
0.3 dose and found that thirty to thirty-four hours elapsed before the temperature 
returned to normal, while in children of ten years or less a dose of 0.15 produced 
the effect in half the time. Of all adults treated two or three showed a secondary 
rise seven or eight days later not exceeding 100. 5 F., which subsided sponta- 
neously in a day or so. 

In concluding I venture to hope that in the discussion this morning some light 
may be shed on the problem not only of training midwives, but of inspiring those 
who are trained with the ambition, for love of humanity, to serve their fellows in 
regions far afield. 



SOME PRACTICAL ASPECTS OF EMBRYOLOGICAL RESEARCH IN 

CHINA 

By 

Paul H. Stevenson, M. D. 

INTRODUCTION 

One of the fine inspirations that has come to the laboratory workers of this 
institution from the week that is just drawing to its close is to be found in the 
genuine interest manifested by so many of the visitors in the various research 
activities upon which these workers are engaged. The readiness, in most cases the 
eagerness, with which the vast majority of medical missionaries in China are will- 
ing to put to practical test and actual use every advance in the knowledge of medi- 
cal conditions in China that this or any other institution is able to place at their 
disposal constitutes a very real stimulus to those whose days are spent among 
test-tubes and microtomes. Although this interest is particularly manifested with 
respect to progress in the diagnosis and treatment of the diseases that are peculiar 
to China and with which many have had little or no opportunity of coming into 
contact before taking up their present work in China, yet the same expectancy 
and willingness to profit by our studies along more generally scientific and less 
strictly clinical lines (such as physiology, biochemistry, and anatomy) is also 
evident upon every hand. It will be quite impossible for those of us so employed 
to return to our work without the feeling that the opportunities and obligations 
naturally imposed upon us by the inherent spirit of the work that engages us, will 
be multiplied several times by this added consciousness of the confident expect- 
ancy on the part of the large numbers of medical missionaries in actual clinical 
contact with the great masses of Chinese. 

It is with pleasure, therefore, that I am able to report briefly upon the begin- 
ning of a particular type of research which is being undertaken in the anatomical 
laboratories of this institution and which, in addition to its broader interest along 
the lines of anthropology and racial embryology, is capable of making a specific 
contribution to the solution of some of the clinical problems of those engaged in 
obstetrical and gynecological work among Chinese women. Viewed in this light, 
the work in question represents not so much an effort to collect and preserve a 
type of material which, though plentiful in China, is very seldom preserved and 
made available for scientific study, as a start towards the investigation of the 
causes and conditions which bring about the waste of human life that this ma- 
terial represents. The matter of collecting as large a number as possible of Chinese 
embryos, fetuses, and abnormal products of conception, must of course be the 
first consideration in a work of this kind, and will continue to occupy much of the 
time and attention of the investigators for some time to come. But it is hoped that 
the time will come, and that not too far removed, when an increasing interest 
on the part of an enlarging number of contributors will insure an adequate and 
continuous supply of embryological material from the four corners of China, and 
the routine of receiving and properly caring for the collection will be in the hands 

334 



OBSTETRICS AND GYNECOLOGY 335 

of a qualified assistant, allowing the laboratory staff to give all its time to the 
study of the many interesting problems that the material represents. 

A detailed report (1) of the collection up to April 1, 1921, is to be found in a 
recent number of the China Medical Journal, and you are referred to this for 
detailed information as to the progress already made along the line of collecting 
and preserving this type of material. For our purpose this morning those features 
of the work will be reviewed which place special emphasis upon some of the more 
practical problems involved. 

The complete list of specimens at the end of the report referred to above and 
more particularly the appended summary of the list by individuals, seeks to give 
credit to each person who has contributed to the collection. A casual analysis of a 
revised summary of those contributors reveals the significant fact that of the 187 
specimens, 135, or 72 per cent, have come from women physicians. It is also in- 
teresting to note further that of the entire number of specimens in the collection, 
1 14, or considerably more than half of the whole collection, have come from the 
large clinics of only four women medical missionaries. 

These facts are mentioned here because they emphasize not only the degree to 
which the women physicians of China are today in practical touch with an im- 
portant field of medical work which still remains very largely closed to medical 
missionaries of the opposite sex, but also, evidenced by the four women who have 
furnished more than half of the entire collection from the material of their four 
respective clinics, the fact that the difficulties in the way of building up a large 
maternity work among the Chinese women are not as insuperable as is usually 
supposed. The evidence of this collection, as well as the personal observations of 
the writer of this paper during a recent trip among the mission hospitals of 
Central China, convinces him that where there is a real desire on the part of the 
physicians in charge of a women's work to enter into this field of needed service; 
and where tactful announcement and solicitation is made among the large number 
of pregnant women who come to the daily clinics for the treatment of other con- 
ditions, but who would in the natural run of events go as a matter of course to a 
Chinese midwife to be multilated at their time of confinement, there is a ready and 
grateful response. 

EMBRYOLOGICAL RESEARCH IN CHINA 

So much for the general points of interest connected with the collection and 
some of the implications which an analysis of the sources of the specimens makes 
possible. We turn now to " Some Practical Aspects of Embryological Research in 
China." 

We are dealing in the last analysis with those'products of conception among the 
Chinese which, usually through imperfect development or maldevelopment, or 
because of an abnormal or diseased environment, or because of artificial interfer- 
ence, or for any other reason, fail to pass safely through the normal period of 
gestation and become new normal living individuals. The problems associated 
therewith reduce themselves into the determination of the rate of prenatal death 
among the Chinese, an investigation into its causes, and the subsequent inven- 
tion of means towards its prevention. Of these, the first two naturally take pre- 
cedence over the third, and it is with these that the work under consideration is at 
present concerned. 



336 PEKING UNION MEDICAL COLLEGE 

The difficulties in arriving at an accurate conclusion concerning the frequency 
of abortion among any people increase proportionately as these people are re- 
moved from scientific medicine. Statistics along this line in America are just now 
becoming available, yielding estimates of one abortion for from every 2.3 Taussig 
(2) labors to every 5 Williams (3) labors. Of conditions in Europe, Franz (4) 
places the figure for abortions at 15.4 per cent in a typical lying-in hospital in 
Germany, Malins (5) reports 19.23 per cent of abortions in a representative 
series of 2,000 pregnacies in England, while Ballantyne (6) quotes Tarnier and 
Budin (7) to substantiate his claim that throughout Europe in general the fetus 
at the beginning of intra-uterine life runs about a 25 per cent risk of never reaching 
the time of viability. With the possible exception of that of Taussig, all of the 
above estimates are admittedly too low, failing to take into account very early 
abortions as well as an estimation of those cases failing to come into the hands of 
medical practitioners. To the above is to be added, by deduction in the case of the 
human, a percentage of normal prenatal deaths, with degeneration and absorp- 
tion of the early zygote, which is now known to exist in the case of all animals 
studied. Robinson (8), who has contributed most to our very recent knowledge of 
this factor, estimates that this normal prenatal death rate in the human family 
under our present conditions of living amounts to over 40 per cent. This figure, 
though purely speculative in the case of the human, is nevertheless a very con- 
servative estimate according to our more definite knowledge of conditions in other 
forms. 

Turning now to specific inquiries along similar lines among the Chinese, it is 
only reasonable to expect that the prenatal death-rate here, both the normal 
which we have just mentioned and the more or less avoidable abortions with 
which we meet more commonly, will be found to be not less high than in Western 
groups of the human family. A careful study of accumulating records will be 
necessary in order to arrive at accurate conclusions concerning these questions. 
This is obviously a matter for the future, but it serves our purpose today to em- 
phasize the importance of these records at this time of early beginning, as well as 
to indicate a few of the specific lines of inquiry upon which it is desirable that they 
contain data. 

CAUSES OF EARLY ABORTIONS 

Spontaneous expulsion of the ovum in the early weeks of pregnancy is invaria- 
bly accompanied or caused by fetal death, and, as Williams (3) points out, any 
consideration of the etiology of abortion in this stage resolves itself practically 
into determining the cause of the fetal death. Mall (9) in turn maintains that a 
very large percentage of these early fetal deaths is due to abnormalities of develop- 
ment which are usually inconsistent with life. Had these lived on, as is sometimes 
the case, they would have produced one of the several types of monster which are 
not infrequently seen. As to the factors directly concerned with the production of 
these abnormalities of development, the student finds an endless contradiction of 
opinions. Mechanical, toxemic, microbic, and toxic agents, have each and all been 
invoked as explanatory causes. Aside from the abnormalities in the development 
of the embryo itself, Mall's studies showed further that abortions at this early 
stage resulted also from abnormalities in the fetal appendages which interfere 
with the nutrition of the fetus (9). Serious studies into the causes of these early 



OBSTETRICS AND GYNECOLOGY 337 

degenerative and abnormal developmental changes in forms other than human 
have been carried out along the lines of the condition and health of the parents; 
the environment and food of the parents; the age of the parents; excessive service 
on the part of the male; the health of the environment of the gametes and the 
resulting zygotes; the nutrition of the fertilized ovum, and the constitution of the 
gametes, and the possibilities of individual variations therein conducive to in- 
compatibility in the case of certain matings (8). Although the results of these 
investigations have so far been scant from the standpoint of positive knowledge 
gained, yet the list of factors considered is suggestive. Among some of the lower 
classes of the Chinese such factors as the health of the women, early and fre- 
quently incompatible marriages, marital unhappiness, frequent hysterical fits of 
unrestrained anger on the part of the women in the home, probable excessive in- 
tercourse, the practice of prolonging lactation to avoid pregnancy, and other 
causes, suggest themselves as possible factors in this subtle problem of the failure 
of many early ova to develop and their subsequent expulsion. n i'i' ;J 

Demonstrable abnormalities in the generative tract of the female, arrested 
development or infantilism, malpositions of otherwise normally formed organs, 
chronic metritis secondary either to malposition or to infection, any other con- 
ditions bringing about circumstances unfavorable to implantation and later nu- 
trition of the ovum, may be expected to account for their share of early abortions 
in China as well as elsewhere. These physical and pathological factors in the 
generative tract of the mother, although belonging more strictly to the gynecol- 
ogist than to the embryologist, are nevertheless factors which will have a direct 
bearing upon the results of the present studies if they are found to exist with dis- 
proportionate frequency among the Chinese. Taken by and large, it is hardly to 
be expected that special conditions in China will add to or subtract from the 
number of fundamental factors concerned in these early abortions, yet the 
detailed study of the embryo, sac, chorion, decidua, and uterus in as many cases 
as possible cannot fail to add to our general knowledge of this difficult subject, 
and help to clear away the clouds that so envelop it in mystery at the present 
time. 

CAUSES OF LATER ABORTIONS 

Passing on to the consideration of abortions and miscarriages in the later 
months of pregnancy, we feel ourselves upon more solid ground and in possession 
of more tangible facts. What are some of the questions which a study of the 
records and of the specimens themselves ought to answer? 

In contradistinction to the abortions of the earlier weeks of pregnancy, these 
later abortions are usually due to interference with the placental circulation of 
the fetus through disease or abnormal development of the decidua, and not to the 
death of the fetus per se. The physical and pathological conditions of the female 
generative tract that have just been mentioned in connection with early abor- 
tions may also exert a latent influence and constitute the predisposing cause of 
abortions in the later months. Infectious diseases, either by the transmission of 
toxins or less frequently the specific organism itself from mother to child, may 
be expected to act in China as elsewhere as a factor in the production of abortions. 
In Central and Southern China, Dr. J. P. Maxwell has found that malaria is a 
causative factor in a very large percentage of abortions every year; these may be 

23 



338 PEKING UNION MEDICAL COLLEGE 

prevented, however, by the prophylactic administration of 4 to 5 grains of 
quinine daily to all pregnant women throughout their term of pregnancy. 

The rapid spread of syphilis throughout China, especially in the port cities 
and along the projecting railroad lines, offers a unique opportunity for the study 
of the relative frequency of late abortions in regions as yet practically free from 
the disease as compared with those already infected. The influence of plagues and 
famines, and the resulting malnutrition and bone diseases, especially the osteo- 
malacia of Shansi and Kansu, the possible effects of foot binding on the develop- 
ment and shape of the female pelvis, and other factors suggest themselves as 
worthy of investigation in connection with the larger problems of the prenatal 
death-rate of the Chinese. 

Observations along most of these lines have already been started. In connec- 
tion with questions of nutrition, famine, maternal syphilis, and foot binding, we 
must not fail to mention the unique opportunity to investigate the effects of these 
factors which was afforded by the large work of Drs. Jean I. Dow and Isabelle 
McTavish of Changteh, Honan, when they delivered and cared for nearly five 
hundred babies from among the women of the famine district during the winter 
of 1 921 . It is to be hoped that complete reports of this unique service will soon be 
available. 

CONCLUSION 

The general trend of this paper has purposely been almost entirely suggestive 
in nature. The work which we have ventured to bring to your attention is not of 
a type which can be carried on by any one single investigator or by any one 
isolated laboratory. Most of the questions suggested await for their solution the 
gathering of a very much larger number of specimens, and the studies of many 
more investigators working on the material in this and in other collections and 
on the records thereof. It is to be hoped that an increasing number of medical 
men and women in China will find an opportunity to spend longer or shorter 
periods of time in laboratories, working on some of these problems and making 
definite contributions to our knowledge and the literature of the subject. Such 
work, as suggested in the preliminary report referred to above (1), ought to provide 
not only a pleasant vacation to a medical worker, but at the same time furnish 
a distinct contribution to the scientific study of conditions among the Chinese 
people. 

BIBLIOGRAPHY 

1. Stevenson, P. H., China M. J., 1921, xxxv, 503. 

1. Taussig, F. J., Prevention and treatment of abortion, St. Louis, 1910. Quoted by 
Williams (3). 

3. Williams, J. W., Obstetrics, 4th edition, New York, 1919, 661. 

4. Franz, K., Beitr. z. Geburtsh. u. Gynaek., 1898, i, 493. 

5. Malins, E., J. Obst. and Gynaec. Brit. Emp., 1903, iii, 307. Quoted by Williams (3). 

6. Ballantyne, J. W., Manual of antenatal pathology. The foetus, Edinburgh, 1902, 455. 

7. Tarnier, E. S., and Budin, P., Traite de l'art des accouchements, 1888, ii, 474. 

8. Robinson, A., Edinb. M. J., 1921, n. s., xxvi, 137, 209. 

9. Mall, F. P., J. MorphoL, 1908, xix, 1. 



DEPARTMENT OF PATHOLOGY 

INCLUDING JOINT SESSIONS WITH THE 

DEPARTMENT OF SURGERY 



PRESENT DAY ASPECTS OF PARASITOLOGY 

IN CHINA 

By 

Ernest C. Faust, Ph.D. 

Several epochal discoveries in medical parasitology have been contributed by 
workers in China on Chinese material. Fasciolopsis buski, the large intestinal 
fluke of man, is peculiarly a parasite of the Chinese, with a special endemic area 
in Chekiang Province. Clonorchis sinensis was first recovered from the liver of a 
Chinese. Although Schistosoma japonicum was first described from Japan, it was 
being studied contemporaneously by Logan at Changteh. One needs only to 
mention the great stimulus to life history investigation produced by Sir Patrick 
Manson, at the time working in Amoy, on the periodicity of Filaria bancrofti. A 
more recent species, Filaria circumocularis, has been described from the eye of 
man and of the dog from North China, Fukien, and has likewise been found in 
Anhwei. 

In spite of this work, the vastness of the country, coupled with the need for 
first-aid for the suffering millions of China, has prevented the development of 
medical parasitology as the subject warrants. For that reason surveys to deter- 
mine the extent of parasitic infections in particular areas are illuminating in 
identifying the parasitic species present, the extent of infection of each species, 
the life histories of such parasites, and the pathological pictures of each infection. 

Various methods are suggested for approaching the problems involved. Routine 
examinations carried on in the clinical laboratories of hospitals in strategic centers 
provide a helpful basis for determining such parasitoses. But they are frequently 
inadequate, due to lack of time and insufficient preparation on the part of labora- 
tory technicians. Intensive examinations covering the same areas are much more 
fruitful. These may be conducted for stated periods to determine the incidence of 
infection and to secure samplings of the whole population or of particular groups. 
When these data are supplemented by information on the infection of domestic 
animals acting as reservoirs of human parasites and of animals acting as inter- 
mediate hosts of such parasites the data are even more suggestive. Such a survey 
indicates a much greater prevalence of protozoa and helminths as actual and 
potential parasites of man than ordinary examinations reveal. 

In certain areas of China parasitic infections are of primary clinical importance; 
in other areas they are incidental. The state of our present knowledge leads one to 
divide China into two climatic regions, arid North China and the moist regions of 
the Yangtze Valley, and the South. In the former, amoebic dysentery, kala azar, 
tertian malaria, echinococcosis, ascariasis, and ankylostomiasis are diseases which 
compel the attention of the clinician. In the Yangtze Valley, amoebiasis, giardiasis, 
tertian, quartan, and estivo-autumnal malarias, bronchial spirochetosis, fluke 
infections, ascariasis, ankylostomiasis, and filariasis are all frequently found as 
primary agents of disease. Because of climatic conditions in the Yangtze Valley, 
schistosomiasis, clonorchiasis, and fasciolopsiasis are important pathogens. 

34i 



342 PEKING UNION MEDICAL COLLEGE 

In addition to the parasites mentioned there are some which occur occasionally 
as primary agents of disease and others commonly found but not regarded as 
provoking a severe pathological condition. 

The increased interest on the part of practitioners, coupled with the widened 
viewpoint in medical parasitology due to the introduction into this field of specific 
protein sensitization tests, culture methods, and new theories of therapy, and 
particularly the relating of clinical symptoms to life histories, make the prospects 
bright for parasitology in China. 

ACCOMPANYING DEMONSTRATIONS 

i. Common parasites of the Yangtze Valley. 
1. Virofilaria immitis. 

a. Gross specimen in heart. 

b. Immature larvae. 

c. Mature larvae. 

3. Variations in FascioZopsis, human and hog. 

4. Schistosoma japonicum. 

a. Mature Worms cf and 9 . 

b. Mollusc host in Japan. 

c. Gross organs from postmortem. 

d. Sections of liver showing cirrhosis. 

5. Clonorchis. 

a. Tissue of liver showing pathology. 
b- Egg. 

c. Gross pathology, cat, dog. 

d. Specimen from cat, dog. 

e. Human case. 

6. Malaria. 

a. Estivo-autumnal, premortem and postmortem. 

b. Tertian. 

7. Embadomonas sinensis, nov. spec. 

8. Spiroschaudinnia. 

a. Carteri, from blood. 

b. Eurygyrata, from feces. 

c. Bronchia/is, from sputum. 

9. Gnathostome from cat. 

10. Filaria from ant-eater. 

a. View of animal. 

b. Stereogram of pathological picture in liver. 

c . Demonstration of worms. 

11. Echinococcus from liver of man. 




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CERTAIN ASPECTS OF PARASITOLOGY IN THE PHILIPPINES 

By 

Frank G. Haughwout, M.D. 

Gentlemen: 

In beginning this talk I feel I must apologize to you for its exceedingly sketchy 
nature, for until I arrived in Peking I had no intimation that I was to address you. 
We must blame that on the fact that the letter informing me of this passed by 
me as I was en route between Manila and Peking. So now I must add to the 
admiration and delight that your hospitality and this beautiful plant have 
awakened in me, the pleasure of presenting a few of my hobbies to you. 

The work in tropical medicine in the Philippine Islands was organized on an 
extensive scale years ago, and soon after, a series of surveys was undertaken with 
the idea of outlining the problems involved. This was done very well as far as it 
went. Then evil days fell upon the Philippine Islands. Since 1913-14 practically 
no productive work has been done along any of those lines, and today the prob- 
lems of parasitology must be re-undertaken. 

We are now at the close of the spectacular era in tropical medicine, the era that 
was exemplified by the work of Laveran, Manson, Ross, and other men of that 
group. We were able to build on the foundations laid by these men and to develop 
the science on a sanitary and curative basis. As a result, the present nature of the 
problems is more distinctly biological and demands the work of the pure scientist. 
While it would doubtless be dull and dreary work for the clinical man, it is to my 
mind the dawn of a new day for the worker in pure science along parasitologic 
lines. With regard to my own work in Manila, I imagine that my position is simi- 
lar to that of Dr. Faust here in Peking, in that I have to handle practically the 
whole department of parasitology. 

There are a number of interesting problems to be worked out in this connection. 
This morning, however, I wish to deal particularly with the question of intestinal 
infections, with merely a passing word in regard to the general types of parasites 
found in the Philippines and the diseases for which they are responsible. These 
are much the same as in other tropical countries. We are fortunate in escaping 
many diseases of the tropics, such as kala azar and those due to some of the 
spirochetoses. We have the intestinal spirochetal infections, but they are appar- 
ently not pathogenic, and this field is restricted largely to the luetic and yaws 
infections. Spirochaudinnia bronchialis occasionally is found. We also frequently 
come across skin ulcers where search reveals spirochetes and fusiform bacilli. We 
have, of course, the malarial and helminthal infections. The general run of intesti- 
nal flagellates are found, such as Trichomonas, Cbilomastix, and Giardia, and very 
recently I have found the sporozoan parasite, Isospora hominis. Among the cili- 
ated protozoa is Balantidium colt, but this is not common. A very important 
group of protozoa includes the intestinal amoebae, Entamoeba histolytica, Entamoeba 
coli, Endolimax nana, Bientamcebafragilis, and Iodamceba butschlii. I reserve judg- 
ment on the last named organism because I have not had an opportunity to study 
it thoroughly. 

343 



344 PEKING UNION MEDICAL COLLEGE 

In the study of human parasitism we miss much by the neglect of the factors of 
evolution. We fail to consider our parasites as strictly as we should from a bio- 
logical standpoint. In this part of the world we are driven to deal with prevailing 
conditions, and we seek first, of course, to relieve clinical symptoms. This had led 
us in the past to a sort of empiricism in parasitology that has held back the science 
to a considerable degree. A remark made by Dr. Faust yesterday morning bears 
very closely on this point, and I agree with him that we should make greater 
efforts to correlate the life cycle phases of our parasites with the symptoms of the 
diseases they produce. Great advances would be made in the treatment of dis- 
orders were it always possible, for example, to administer the necessary drug 
when it would be most efficacious, that is at the most vulnerable period in the 
life cycle. In the treatment of malaria, for example, we are accustomed to admin- 
ister quinine at a time when the blood stream contains the sporulating parasites. 

MALARIA 

The story of malaria in the Philippine Islands is practically the same as in other 
tropical countries. The disease presents the same recurring symptoms and follows 
the same general course. All three types are found, tertian, quartan, and estivo- 
autumnal. The prevailing type is probably the estivo-autumnal, but benign 
tertian infections are very common, and not infrequently both infections are 
found in a single patient. 

One of our most interesting problems, however, is in connection with malaria. 
For many years we flattered ourselves that we knew everything about the life 
cycle of the plasmodium of malaria; but we have yet to determine the cause of 
malarial latency and relapses; what conditions exist within the human host that 
lead to the persistence of the infection over long periods of time and what condi- 
tions supervene to break down the resistance of the host — and incidentally what 
the parasite has been doing all that time. 

THE HELMINTHS 

With regard to the helminths: The records show only one indigenous trematode 
in the Philippines, the Echinostoma ilocanum, reported originally by Garrison (i) 
from a rather restricted area north of Manila. It was subsequently investigated 
by Hilario and Wharton (2), but in no case was it possible to work out the life 
cycle. Our helminthal infections are largely restricted to the nematodes. Trichuris 
is probably the most common of the helminths found in the intestinal tract. In a 
series of subjects which I studied it was present in 69 per cent. Jscaris is also 
exceedingly common, particularly in children, where the infections occasionally 
reach a very massive stage and are quite similar to those here in China. Filariasis 
is present in several localities. For the most part the larvae do not show diurnal 
periodicity in the blood, and elephantiasis is almost unknown. Among the ces- 
todes, 'Tcenia saginata is probably the prevailing species, but more research is 
needed in this direction. Occasionally we get an infection with Hymenolepis nana. 

The incidence of hookworm in the Philippines varies with the locality, and this 
problem is at present undefined. Much work has been done on hookworm infec- 
tions, but there is apparently no record as to the probable distribution of the 
species. It is very important for us to know something regarding the dominant 



PATHOLOGY 345 

species of hookworm. In my opinion, it is probably the Necator americanus. Here- 
tofore, hookworm investigation in the Philippines was considered relatively unim- 
portant, partly because, although the disease was more or less prevalent, the 
natives did not seem to be seriously affected by the parasite. Many immigrants, 
however, from China and Malaysia are apparently importing ankylostomiasis, 
and a large number of the American population have become infected with the 
disease. Consequently, unless care is exercised, serious trouble seems imminent. 

THE FLAGELLATES 

A question of vital importance bears upon the pathogenicity of the intestinal 
flagellates. Although the literature on this subject is enormous, direct evidence in 
regard to the matter is almost totally lacking. Personally, I regard these flagel- 
lates as a separate race of protozoan organisms, like other intestinal parasites of 
pathogenic significance, pursuing their course entirely apart from any other living 
organism in the intestine. One thing that impresses me very sharply in regard to 
them is that an apparent process of evolution appears to be taking place in one 
group in particular, the trichomonads. I have seen these organisms appear in 
stools under all circumstances. Frequently in the passages of bacillary dysentery, 
I have encountered them swimming about among the blood corpuscles without 
ingesting any of them whatever. On the other hand, there have been instances of 
similar physical conditions where trichomonad flagellates ingested blood corpus- 
cles and digested them. This to me, is a very strong indication of a growing 
adaptation in certain races of these flagellates to obligatory tissue parasitism. 
Hadley (3) has taken up this problem in some of the lower animals and has de- 
scribed a method of invasion of the intestinal mucosa through the goblet cells. 
More recently Wenyon (4) has described his findings in a man in India, where 
precisely the same performance has apparently taken place. 

While it is barely possible that this invasion takes place under conditions 
supervening immediately after the death of the patient, I doubt it very much 
because the invasion is too deep. I doubt it all the more because within the past 
year I have had an opportunity to study a case of trichomonad infection of the 
pleura in a Chinese in Manila. The organisms recovered from the pleural exudate 
were unquestionably trichomonads of the type found within the intestinal tract. 
They undoubtedly reached the pleura by way of the blood-stream, although 
direct evidence of this fact is lacking. However, if the case proved nothing else, it 
proved at least that trichomonad flagellates of a distinctly intestinal type are 
capable of living in other parts of the body. That, to my mind, is added evidence 
of the possible evolution of the race of these parasites towards obligatory tissue 
parasitism. 

COCCIDIOSIS 

A recent investigation of interest has been made in regard to human coccidiosis. 
Up to the time of the war, the literature on this infection had been in a very 
chaotic state. In 1915, the laboratory work of the British and French was organ- 
ized on an extensive basis, under such able protozoologists as Colonel Wenyon, 
Professor Dobell, Colonel Woodcock, and others. One of the first discoveries made 
was that of coccidiosis in man, in a soldier invalided home from Mesopotamia. 
In the feces a cyst of Isospora was recognized. Other cases were observed, and 



346 PEKING UNION MEDICAL COLLEGE 

they all came from a strip of land running southeasterly from the Balkans, across 
the Mediterranean, down into Mesopotamia. Castellani (5), in 1917, reported 
coccidiosis as common in the Balkans. During the next two or three years new 
species of human coccidia were definitely reported and studied. These included 
Eimeria wenyoni, Eimeria oxyspora, and Isospora hominis. Subsequently Snijders 
(6), in Java, reported an isolated case of still another species, now known as 
Eimeria snijdersi. With this exception the endemic area of all the species centered 
around Mesopotamia, and cases of the disease which appeared in other parts of 
the world were almost all traced to that locality. Four of the cases, however, 
encountered in New York City were in the Home Service Troops, which raises 
some suspicion of their being autochthonous. 

A case of infection with Isospora, the European coccidiosis, came under my own 
observation in Manila in 1921 (7). I was tremendously interested because I had 
predicted in 1917 that this very thing would happen. The man's history revealed 
that he had been associated in the United States with soldiers returned from the 
war and with laborers drawn from the Eastern Mediterranean area. His infection 
lasted at least four months, because he was still infected when I sent him back to 
the States. During his stay in the Philippines he traveled through a very wild and 
insanitary district in Mindanao. It will therefore be very interesting to discover 
whether this infection spreads in that region in the future. 

It is difficult to know just how to treat these cases of coccidiosis. Ipecac, emetin, 
thymol, and salvarsan have been tried without results. The parasite, as you know, 
is an epithelial cell parasite probably of the upper intestinal tract. This suggests 
again the question of life cycle and treatment mentioned by Dr. Faust. We can- 
not treat these cases logically without regard to the life cycle of the infecting 
organism. The treatment of coccidiosis in man should rest on much the same 
principle as the treatment of malaria. I regard the chances of effecting cures in 
these cases as remote at best, and we cannot accomplish anything at all unless 
the drug reaches the bowel at the time when conditions are most suitable; that 
is, when sporulation is taking place. The difficulty here lies in determining when 
multiplication or schizogony takes place and when the merozoites are formed. It 
was rather significant in the case I have cited that there was a definite tertiary 
periodicity in the character of the stools, which to my mind is possibly indicative 
of the period of merozoite formation. 

BALANTIDIAL INFECTIONS 

The balantidial problem is one that is particularly interesting to me from the 
zoological standpoint. Little is known regarding the life cycle of the Balantidium 
coli. Several years ago Walker (8) made a study of balantidial infections in man 
and also in the pig, and he concluded at that time that most of the human in- 
fections came from local pigs. The infestation of pigs in Manila by this parasite is 
very large, quite as large, I imagine, as it is in some parts of China. Dobell (9), 
however, in the course of extensive studies in England, failed to find a single case 
of balantidial infestation in man, whereas the pigs are heavily infested. This raises 
the whole question of species. In my opinion the species of the pig host is not the 
same in England as it is in the Philippine Islands. Moreover, the infestation in 
American and British pigs is said to be confined to the lumen of the bowel. In pigs 



PATHOLOGY 347 

in the Philippines, however, the Balantidium penetrates the mucosa and comes 
to rest in the submucosa, behaving in precisely a similar manner in both the pig 
host and the human host. But it is strange to note that in pigs we frequently 
recover Balantidium in the encysted form, while in human infections cysts are 
very rarely found. Dr. Walker in his series of cases was fortunate enough to find 
two or three instances of encystation, but I myself, have never found a cyst in 
human feces. I am, therefore, inclined to believe that the Balantidium is specifi- 
cally a parasite of the pig in the Philippine Islands with rather incomplete adapta- 
tion to the human host. 

We miss a great many balantidial infections because of the absence of clinical 
symptoms that are characteristic of acute balantidial infections; but occasionally 
we come upon a frank case of balantidial dysentery. Not infrequently the patient 
does not survive the attack, and we have an opportunity to study the case at 
autopsy. We find the organism in the intestinal wall accompanied by much the 
same lack of tissue reaction as we see in uncomplicated cases of amoebic dysentery. 
The picture is similar clinically, pathologically, and parasitically. 

DYSENTERY 

Ignorance as to the contributing cause of acute amoebic dysentery is one of the 
most baffling problems that confront us. It is known that the amoeba may inhabit 
certain parts of the human body, principally the submucosa of the large intestine. 
It usually stays there, and, in a large proportion of cases, causes no damage, but 
suddenly in some instances, it precipitates an attack of amoebic dysentery through 
conditions of which we have no information. 

Our knowledge of the life cycle of the amoeba is not complete. We know that it 
forms cysts which serve as the agents of transmission of the organism from host 
to host. The cysts are passed with the bowel discharges and are relatively resistant 
to environmental conditions. I say relatively, because they do resist the action of 
chemical agents of a strength greater than those ordinarily present in food sub- 
stances or in drinking water. They do not resist the influence of bacteria in con- 
centrated growth nor of desiccation, but they do resist the ordinary conditions 
that prevail. If the cyst leaves the intestine in its fully developed stage it is, 
barring accident, capable of infecting a new host. It is my belief that the most 
frequent method of infection for this organisnris through the medium of carriers, 
mainly contact carriers. I think that the chances of infection through the drinking 
water are relatively slight; that it does occasionally take place, but that it is not 
the most frequent mode of infection. Fly transmission is, I believe, very important. 

The cysts enter the intestine of a new human host, pass through the stomach, 
and enter the small intestine, and there for a time we lose track of them. It is a 
more or less generally accepted belief that these cysts open in the small intestine 
under the influence of the digestive juices there. I do not consider that this point 
has been proved by any means, however. We have knowledge of the life cycles of 
many free living protozoa, and we know that in many cases those species that 
form cysts leave their cysts not through the direct influence of environmental 
conditions, but by reason of causes wholly within themselves, the whole thing 
being precipitated, as it were, by an external stimulus of some kind. I am inclined 
to believe that such a process does take place in the case of Entamoeba histolytica 



348 PEKING UNION MEDICAL COLLEGE 

which, as is well known, is an obligatory parasite of the large intestine, not of the 
small. If these cysts open in the small intestine the amoeba within them, which 
are obligatory tissue parasites and are incapable of digesting any other food than 
they find in the intestinal tissue, have a long journey down to their definitive site. 
Ultimately, however, the amoebae arrive in the large intestine, and a certain pro- 
portion of them leave the cysts, whether in a mononuclear or quadrinuclear state, 
I cannot say. They penetrate the intestinal mucosa and rest in the submucosa, 
probably causing relatively little damage. They make their way rather rapidly 
to the submucosa, where they stay. They feed on what they find there, and con- 
sequently reproduce, and in the course of time the infection becomes rather 
intense. I am of the belief that in the very early stages of these infections cyst 
formation does not take place, but in due course of time it begins. It may be a 
week or two, or even longer, before we detect it. The time arrives, however, when 
it is necessary to establish a balance between the host and the amceba. This 
balance is maintained when cyst formation begins and a certain proportion of the 
amcebae give up their trophic life, that is, the life in which they are digesting and 
ingesting food. They then become physiologically transformed. Probably at that 
period when physiological transformation is beginning they pass out into the 
intestinal lumen and become morphologically transformed. Effete matter, food 
that has been accumulated, and a certain proportion of water are expelled. The 
amceba rounds out and the animal assumes the precystic form. Shortly after- 
wards it encysts. 

It is true that possibly some condition may supervene within the host that 
leads to suppression of cyst formation. If this takes place one can readily see that 
the tissue will become overrun by amcebee, and mechanical pressure will bring 
about a process that will ultimately lead to ulcerative developments. It may be 
that the endocrine system exerts some influence. There may occur from time to 
time in the host the removal of some inhibitory influence or the development of 
some stimulating influence that will bring about the reproduction of the amceba 
at a rate more rapid than can be compensated for by the normal reparative proc- 
esses of the host. 

A point I had not intended to take up this morning was suggested by a casual 
remark by Dr. Mills. This is in regard to the value of the microscope in the 
diagnosis of both amoebic and bacillary dysentery. I am a strong advocate of the 
use of the microscope, but long experience has taught me that in dealing with 
intestinal infections, the microscopist should be in very close harmony with the 
clinical man. In Manila, at present, we make our diagnoses of dysentery, no 
matter what the type, by the microscope. I usually check this, because I am col- 
lecting statistics, with the findings of the bacteriologist, who at best is working 
under great disadvantages; but I no longer rely upon his methods, for I believe 
that in the majority of cases an experienced man can make a very accurate differ- 
ential diagnosis under the microscope very soon after the patient comes in for 
treatment; whereas if we wait for the bacteriological diagnosis we are fighting 
against fate, we are possibly going to lose, and the patient may die if he has an 
acute dysentery. 

During the late war, a very excellent paper was published by Willmore and 
Shearman (10), in which they assembled and summarized much information 



PATHOLOGY 349 

regarding the cytology of the dysentery stool that many of us, especially in the 
tropics, had known in a vague and general way for years. Wenyon and O'Connor 
(11) have taken up very much the same subject, and later Woodcock (ia) sum- 
marized the matter; so that the ground has been covered very thoroughly. 

Briefly, in the general run of dysentery cases, the bowel exudate is more or less 
characteristic of the type of dysentery, particularly in protozoan and bacillary 
dysenteries. In bacillary dysentery as you know, the onset is apt to be sudden. 
Very early in the progress of the disease an exudate occurs consisting largely of 
polymorphonuclear neutrophiles, more or less in a state of disintegration with a 
great amount of mucus and blood. That in general is the characteristic stool of 
bacillary dysentery. But there are other considerations. For instance, careful 
study of the stool, will sometimes show that a so-called "amoebic dysentery" is 
what I might characterize as an "amoebic dysentery of the endothelial cell 
type." In other words, it is bacillary dysentery. Examination will show that cells 
of the mononuclear type are almost completely lacking. Moreover, there will be 
abundant epithelial cells, endothelial cells, and macrophages, many of which 
unfortunately have been mistaken for amoebae by inexperienced workers and the 
cases labelled "amoebic dysentery." But these stools, in frank bacillary dysentery, 
bear the stamp of toxic necrosis. There is an abundance of the large macrophage 
cells, not infrequently containing red blood corpuscles, which cannot be mistaken 
after they have been seen a few times. 

A few months ago I was called upon to investigate an alleged epidemic of 
amcebic dysentery. I was more or less skeptical, because I have no great belief in 
epidemics of amcebic dysentery. Before I had been a week at the seat of the 
trouble I felt that this outbreak was not amcebic dysentery at all but a dysentery 
of the "endothelial cell type" just described. It was finally shown that it was a 
bacillary dysentery of the Flexner type. A similar instance occurred in the British 
Army in Mesopotamia. 

Another great source of trouble for us in the tropics is the prevailing opinion of 
the man who comes out from the United States to work that there are two types 
of dysentery. One of these is amcebic dysentery, characterized by the presence of 
amoebae and by the lack of pyrexia and symptoms of toxemia; the other is bacil- 
lary dysentery, with an elevation of temperature to ioi" to 104 F., symptoms of 
toxemia, collapse, and all the other symptoms of severe dysentery. Such general 
clinical diagnoses often give rise to mistakes. 

During the past year or two there have been numerous cases of dysentery 
among our staff in the Bureau of Science in Manila, and the following routine has 
proved very successful in their treatment: The patient wakes up at about three or 
four o'clock in the morning, develops cramps, and soon begins to have rather large 
bowel movements. He comes to the building in time to report, and is sent down 
to my laboratory, where a fresh specimen is examined under the microscope. The 
picture is usually absolutely characteristic of bacillary dysentery. I give the man 
a note to the serological laboratory, where he is injected with 20 or 30 cc. of poly- 
valent antidysenteric serum. Then he goes home, goes to bed, with a hot water 
bottle over his abdomen, and in the majority of instances reports for duty on the 
following day. That man has had bacillary dysentery, but it has been controlled 
very quickly. He has shown his symptoms and has come in promptly; we have 



35o PEKING UNION MEDICAL COLLEGE 

made the diagnosis under the microscope and have given him his serum at the 
very time when he should receive it. If we had waited for the bacteriologist to 
make a diagnosis, the patient would have become much worse. These cases show 
at most only a slight elevation of temperature and no toxemia or collapse. 

All cases of baciflary dysentery are not always satisfactory after the first thirty- 
six hours. But in the general run of Flexner infections the patient will show very 
slight or no febrile symptoms, no signs of collapse, no signs of toxemia. On cultur- 
ing the stools of such cases, in most instances it is shown that the organism present 
is a bacillus of the Flexner type. Out of hundreds of cases of this description that 
I have seen in the Philippines, many have been diagnosed clinically and micro- 
scopically as amcebic dysentery. We therefore cannot be too careful in our diag- 
noses of amcebic dysentery, and I lay down this fundamental principle to my 
students and assistants: "Be very careful of a diagnosis of amcebic dysentery in 
the absence of amcebas." An experienced man will have little difficulty in diag- 
nosing microscopically acute dysentery of the usual types — I am not speaking 
of the clinical diagnosis. An acute case of dysentery should not be missed, and if 
the onset is protozoan in character, the organism should be found. In my own 
experience Entamceba coli is seldom encountered in a stool of a case of well-estab- 
lished acute amcebic dysentery. Lumen-dwelling protozoa usually disappear early 
in the attack, with the exception of certain of the flagellates, some of which will 
persist in crypts and appear throughout the course of a long attack. In the early 
stages of the disease it may be possible to check the diagnosis. The stool may con- 
sist of two very definite portions, a fecal portion and a bloody-mucoid portion. 
In the latter amoebae containing red blood corpuscles are frequently recovered, 
and they may be said to constitute a diagnosis of entamcebic dysentery. A mild 
controvesy is going on in regard to this point, but until we have more definite 
information I think we are entirely justified in considering the presence of eryth- 
rocytes in amcebse as a very important diagnostic feature. In the fecal portion, 
encysted forms are not uncommonly recovered. These furnish a check upon the 
motile forms. Macroscopically the stool may not be dissimilar from the stool of 
bacillary dysentery. Personally I do not consider it safe to inspect a stool without 
the microscope, and pronounce it a stool of bacillary or of amcebic dysentery as 
the case may be. Microscopically in amcebic dysentery you will find mucus and 
blood. In the primary cases you will notice the seeming, indeed the actual, absence 
of polymorphonuclear leucocytes. The cellular exudate will be very scant. As the 
case progresses a secondary bacterial infection may take place, when pus is very 
apt to appear. Such cellular elements as are present in the early stages consist 
mainly of cells of the mononuclear type, and in early uncomplicated cases there 
is a total absence, in the cellular exudate, of any evidence of toxic necrosis. 
Epithelial cells and ghost cells are lacking. Above all, if Entamoeba hystolytica is 
present, it will clinch the diagnosis. That, in a general way, is the fundamental 
picture, but as I have said before, conditions are frequently very misleading, and 
the greatest care must be exercised. 

Among various misleading conditions which may lead to wrong diagnoses, is 
the so-called "chronic bacillary dysentery," resulting from carelessness from a 
post-dysentery standpoint. I myself am skeptical as to the existence of chronic 
bacillary dysentery. The majority of patients of this class that I see are Europeans 



PATHOLOGY 



35 1 



from whom it is relatively simple to obtain exact information. Examination re- 
veals stools laden with amoebae, possibly with Entamceba coli, and in many such 
cases the collection of pus cells is prominent. The feces may be formed but con- 
tains stands of mucus filled with pus cells and epithelium. Clinically, there is 
perhaps a slight rise of temperature, bowel movements are frequent, and the 
patient feels ill. Without proper study such symptoms are misleading. The case 
might easily be diagnosed as bacillary dysentery, whereas in reality the patient 
has a chronic ulcerative process somewhere in the lower bowel. Many such cases 
respond readily to dietary treatment. They seldom, if ever, even under the most 
rigid technical conditions yield a growth of Bacillus dy sentence; they are chronic, 
non-specific, ulcerative processes. 

A case that puzzled me very much was, I finally concluded, probably one of 
mercury poisoning rather than of bacillary dysentery. Although the bowel move- 
ments were frequent and characteristic of the latter condition, and the stools 
were laden with pus, I did not find microphages and the picture of toxic necrosis 
usual in bacillary dysentery. 

Another interesting case was observed by Major J. E. Ash of the Army Medical 
Corps, and myself during an investigation into bacillary dysentery and allied 
conditions in a military hospital. A native soldier who was suffering from pneu- 
monia developed intestinal symptoms. The usual laboratory examination of the 
stool suggested bacillary dysentery. When the matter was referred to me, how- 
ever, I felt doubtful. The patient died and an autopsy was made. Cultures taken 
were negative for dysentery and examination of the colon showed a diphtheritic 
colitis, probably secondary to the lung involvement. There was absolutely no 
evidence of amoebic or bacillary dysentery, and yet superficially, because of the 
presence of the enormous number of leucocytes, the stool resembled that of bacil- 
lary dysentery. 

A curious condition once occurred in a young child, who did not show any 
elevation of temperature, but had been passing stools more or less laden down 
with pus. The case finally reached my laboratory, where by very good fortune I 
succeeded in finding a clue to the situation. There is in the Philippines a plant 
called "gabi" {Colocasia esculentum Schott). In the latex of this plant there are 
little capsules about the size and shape of hookworm ova enclosing a collection of 
sharp-pointed crystals of calcium oxalate. When eaten raw the plant causes 
intense irritation of the buccal mucous membrane. The stool contained a few of 
these capsules and a few free oxalate crystals, and subsequent investigation dis- 
closed the fact that the child had chewed gabi. I may add that in the study of the 
case my identification of the crystals was checked by Professor E. D. Merrill, the 
botanist. 

The question of the cure of amoebic dysentery is purely a clinical matter which 
I am not particularly qualified to discuss, but I feel that there is a great deal of 
work to be done in regard to the modus operandi of the drugs used in the treat- 
ment. The work goes back to the excellent pioneer work of Vedder in Manila (13). 
Dale and Dobell (14) have published a very interesting study on the action of 
ipecac, and its derivatives, particularly emetin and cephalin. They discovered the 
fact that while the toxicity of emetin in vitro was relatively low, that of cephalin 
on the other hand was quite high. But in treatment the results were absolutely 



35^ PEKING UNION MEDICAL COLLEGE 

reversed. Emetin yielded splendid results; cephalin was therapeutically inert. 
Now, what is the answer? 

Ordinarily acute amoebic dysentery is relatively easy to control, except in cases 
that progress to gangrenous involvement of the intestine, where the patients die 
very quickly. A number of drugs are very efficacious. Myristica, or nutmeg, 
yielded splendid results in the hands of Leidy (15). Chaparro amargosa is another 
drug of promise. I have had some good results with benzyl benzoate, but I do not 
believe that any of these drugs, with the possible exception of emetin, has a 
definite amcebicidal action. Many cases seem to respond very favorably to such 
treatment, but they are often incorrectly diagnosed cases or cases that would be 
apt to do well under any reasonable form of treatment. Through the action of 
some drugs the bowel is given a chance to recover itself, but in very few cases can 
anv lethal action on the parasite be shown. In many instances it seems to me the 
treatment may restore the balance and bring about the resumption of the ordi- 
nary conditions by stimulation of encystation of a proportion of the parasites. 

An interesting consideration, which was mentioned by Dr. Faust in discussing 
amoebic dysentery, is the large number of carriers in proportion to the cases that 
develop acute dysentery. He is absolutely right. One of the most interesting ques- 
tions today regarding amoebic dysentery is that the proportion of carriers prob- 
ably far out-numbers the cases that develop acute dysentery. It is not improbable 
that only 10 per cent of carriers develop acute symptoms. I am inclined to think 
that the proportion of cases varies with the race, perhaps due to racial adaptation, 
and that it may be even lower with the Filipinos and Chinese, although higher 
with the Europeans in this part of the world. Occasionally we have followed cases 
of infection in both natives and Europeans for several years, where we have had 
no previous history of dysentery and none of the manifestations of the disease 
have occurred during the period of observation. It is impossible to tell how such 
cases may develop, and whether or not they are going to have an amoebic abscess 
of the liver, or more properly speaking, hepatic amcebiasis. I am of the belief that 
any carrier should be treated promptly. 

INCIDENCE OF PARASITISM 

It is a little difficult to discuss the relation of parasites to human beings in the 
Philippines because the methods of study have changed very radically in the last 
few years. The early work of such men as Musgrave, Walker, Sellards, and Garri- 
son was of a very high order, but I do not know just how far their records will aid 
us under present conditions. I think that a large proportion of infections must 
have been missed, but nevertheless, I found that my own figures regarding the 
incidence of parasitism in a certain group was 90 per cent, 3 per cent below those 
of Garrison and Llamas (16) for a similar group. My studies lead me to concur in 
Garrison's statement that (17): "The population of the Philippines presents a 
higher percentage of infection with intestinal worms than has ever been definitely 
reported from any other people and the condition is essentially a chronic one, the 
results of which manifest themselves indirectly in the general physical impover- 
ishment of the people and the high rate of morbidity and mortality accredited to 
other diseases." 

The study of parasitism in children has been interesting in many respects. Dr. 



PATHOLOGY 



353 



Horilleno, one of my former students, and I divided a group of ioo children into 
three small groups in order to study them (18). The first group included children 
under the age of twelve months, that is, from seven to twelve months. Of that 
group 66.66 per cent were parasitized and infections were found at seven months. 
In the second group, composed of children between the ages of one and two years, 
73.6 per cent were infected. The total percentage of infected children up to two 
years was, therefore, 71.4 per cent. In the third group, consisting of children above 
two years and under thirteen years, 100 per cent were infected, and in many cases 
there was a multiple parasitism. In more than one instance we found six species 
of parasites in one child. 

A very significant thing, however, although I do not know whether it is an 
absolute fact, is the seeming rarity of acute amoebic and balantidial dysenteries, 
even of ordinary infections by these organisms, in children below the age of 
puberty. Filipino children are susceptible to every conceivable parasite. Their 
intestines fairly swarm with Trichomonas, Chilomastix, Giardia, and the non- 
pathogenic amoebae, but seldom, if ever, do we find Entamoeba histolytica or 
Balantidium coli. I have seen a few cases of Entamoeba histolytica infection in 
children below the age of thirteen years, but only one case of balantidial infection. 

BIBLIOGRAPHY 

1. Garrison, P. E., Philippine J. Sc, 1908, iii, B, 385. 

2. Hilario, J. S., and Wharton, L. D., Philippine J. Sc, 1917, xii, B, 203. 

3. Hadley, P. B., Agric. Exper. Station, Rhode Island State College, Bull. No. 168, Nov., 

1916. 

4. Wenyon, C. M., J. Trop. M. and Hyg., 1920, xxiii, 125. 

5. Castellani, A., J. Trop. M. and Hyg., 1917, xx, 198. 

6. Snijders, E. P., Parasitology, 1920, xii, 427. 

7. Haughwout, F. G., Philippine J. Sc, 1921, xviii, 449. 

8. Walker, E. L., Philippine J. Sc., 1913, viii, B, 233- 

9. Dobell, C, Med. Res. Council, Spec. Rep. No. 59, London, 1921. 

10. Willmore, J. G., and Shearman, C. H., Lancet, 1918, ii, 200. 

11. Wenyon, C. M., and O'Connor, F. W., J. Roy. Army Med. Corps., 1917, xxviii, 151. 

12. Woodcock, H. M., J. Roy Army Med. Corps., 1920, xxxiv, 121. 

13. Vedder, E. B., J. Am. M. Assn., 1914, lxii, 501. 

14. Dale, H. H., and Dobell, C, J. Pharmacol, and Exper. Therap., 1917, x, 399. 

15. Leidy, J., Med. Rec, 1919, xcv, 354. 

16. Garrison, P. E., and Llamas, R., Philippine J. Sc, 1909, iv, B, 185. 

17. Garrison, P. E., Philippine J. Sc, 1908, iii, B, 73. 

18. Haughwout, F. G., and Horilleno, F. S., Philippine J. Sc, 1920, xvi, 1. 



24 



CONFERENCE ON PNEUMONIC PLAGUE 

PLAGUE EPIDEMIC IN THE CHINESE EASTERN RAILWAY REGION 

IN 1920-21 

By 

P. LoSTCHILOFF, M.D., AND G. TcHAPLIK, M.D. 

The epidemic first broke out in the autumn of 1920 in a village near the railway 
station of Hailar, on the border of inner Mongolia, among Chinese tarabagan 
trappers. At first seven Chinese in the same "faungza" fell ill and died. Then 
some Chinese soldiers fell ill after visiting this faungza, and next the family of a 
railway guard, who lived in the same building with these soldiers. Finally the 
plague reached the Chinese settlement nearest to the Hailar station. During the 
first period of the epidemic the plague was exclusively bubonic but with the 
beginning of the cold season only cases of pneumonic plague were reported. 

During the whole period of this epidemic, which lasted from October 20, 1920 
to May 27, 1 92 1, the registered number of cases of plague on the territory belong- 
ing to the Chinese Eastern Railway was 1,598 cases, and 2,931 dead bodies of 
plague victims were discovered on this territory. The number of deaths from 
plague amounted altogether to 4,529 cases: 4,179 Chinese victims, or 92 per cent; 
and 350 Russians, or 8 per cent. 

All those who were affected by the pneumonic form of the plague died on the 
second or third day of their illness. From among those who had bubonic plague 
three were cured, including one pregnant woman, who shortly after her recovery, 
gave birth to a healthy child. 

The localities most seriously affected by the plague were the town of Harbin, 
with a total of 1,748 deaths; the settlement of Manchouli with 1,137 deaths; and 
the Chalainor Coal Mines with 938 deaths. The plague reached its maximum 
severity during the months of March and April. The highest per cent of Russian 
plague victims was registered in the settlement of Manchouli station. These were 
destitute refugees and soldiers who lived under very unfavorable conditions and, 
in many instances, were lodging together with poor Chinese. Among the better 
off and more intelligent classes, both Russian and Chinese, cases of plague have 
been very rare. Among the Russian Medical Staff the following persons fell ill 
with plague and died: Dr. Sinitzin, four surgeon-assistants, and twenty-eight 
orderlies. Dr. Yuan, a Chinese, also fell a victim to this plague epidemic. 

As to the bubonic plague, the real source of the first infected cases was not 
definitely established, but in the last plague outbreak, as in previous outbreaks, 
the first victims of the bubonic plague are those who had dealt with tarabagans. 
There has been no positive evidence to prove that the infection spread from arti- 
cles belonging to those infected with plague or from corpses of the plague victims. 
A five-day term of quarantine for people who have been in touch with the plague 
cases should be considered sufficient. Among 2,014 cases of isolated Chinese there 
was only one case registered where the first symptoms of infection appeared on 
the sixth day of the isolation. In most cases the incubation period was three days. 

3J4 



PATHOLOGY 355 

There were no definitely specific symptoms of the plague during the epidemic 
of 1920-21 on the Chinese Eastern Railway. It had the usual symptoms of a 
heavy septic disease. Meteorological data collected during this epidemic show 
that two or three days after there had been cold or wet weather, the number of 
plague cases increased. The probable reason for this is the necessity for the poor 
Chinese to remain on such days within their dirty, crowded lodgings, which are 
often already infected. 

Since the nature of the plague is known, this disease is no longer a serious men- 
ace to men with high standards of hygienic living. The disease spares such people 
even when they happen to live in localities which are the very centers of epidemic 
infection. As regards the region of the Transbaikalian and Mongolian Steppes, 
the plague should be considered endemic and connected with plague epizooty 
among tarabagans. Most convincing proof is given by some cases of bubonic 
plague which were registered in August, 1921 : Two employees of the Chita Rail- 
way, each of whom had killed an infected tarabagan and skinned the animal 
before cooking it, were the first victims of the disease. Almost every autumn at 
the usual time of tarabagan trapping and hay harvest, either single cases or small 
epidemics of bubonic plague occur in Transbaikalia and Mongolia. These some- 
times, as it happened in 1910 and 1920, develop into heavy epidemics. There is 
now an outbreak of bubonic plague in the territory of the Chita Railway. From 
the middle of August up to the first of September six Russians have fallen ill and 
died. This number includes one of the railway doctors who had operated on a 
patient with bubo, which proved to be infected with plague. 

Recent cases of bubonic plague which have occurred in Transbaikalia, do not 
permit us to look with confidence upon the near future. Scientific investigations 
of the real causes of plague epidemics in the Transbaikalian and Mongolian 
regions ought to be undertaken at once. We dare to hope that the Union Medical 
College in Peking, so well and richly equipped, will not refuse its assistance in the 
matter of carrying on these investigations in the epidemic foci of the plague, and 
will thus help to bring to an end one of the curses of mankind. 

Dr. Lostchiloff presented the following supplementary notes: 

During the plague epidemics of 1910 and 1920 in the territory of the Chinese 
Eastern Railway no epizooty of any kind was observed on house rats and mice. 
At the time of the plague epidemic in Vladivostok in the summer of the current 
year (1921) seven dead rats were found, which proved upon inspection to be 
plague-stricken. 

Two places must be considered as epidemic foci, namely: the Astrakhan or 
Kirghiz Steppes, lying northward from the Caspian Sea, and the Transbaikalian 
and Mongolian Steppes in Siberia. The source and carriers of the plague infection 
in the Astrakhan Steppes, as proved by the investigations carried on by Professor 
Zabolotny's Scientific Expedition in 191 2, are fleas from local marmots (Sper- 
mophilus citillus). Being a member of this scientific expedition, I myself observed 
in these Steppes a number of regions (about 10 square yards each) covered with 
bodies of dead, plague-stricken marmots. Experiments proved that healthy 
marmots were devouring these cadavers and becoming infected in turn. 

No scientific investigations have yet been made to discover the reasons for the 
existence of these endemic foci of plague in the Transbaikalian and Mongolian 



356 PEKING UNION MEDICAL COLLEGE 

Steppes, and yet this question is of great importance to China as well as to 
Russia 

There is no reason for considering the Astrakhan Steppes as the origin of the 
plague epidemic in China, the two places lying so far from each other and having 
no direct connection with each other. Up to the present time the plague epidemic 
in the Astrakhan Steppes has been observed only among nomad Kirgizes, wan- 
dering in these Steppes and having no connection with the Russian population. 
Among the latter only a few cases of plague were reported. As far as I know there 
was not one case reported in the region lying between the Astrakhan and the 
Mongolian Steppes, although the last epidemic came from the Mongolian Steppe. 

The plague epidemic in Northern Manchouli which took place in 1920-21, as 
well as the one of the year 1910-11, in places of its most intense developments, 
had a periodic character, lasting, on the average, about three months and in only 
two points, on the territory of the Chinese Eastern Railway, namely, in the 
adjoining settlement, in Manchouli and at the Chalainor Mines. Cases of plague 
during the epidemic of 192 1, having been reduced to a minimum at the end of the 
third month, became more frequent again owing to new cases brought from other 
places. 

With the coming of the warm season the epidemic of the pneumonic plague in 
1921, just as in the year 191 1, gradually disappeared everywhere except in Vladi- 
vostok, where plague appeared in April and lasted till the month of July. (It can 
be explained by the considerable humidity of the atmosphere in summer in this 
seaside town.) The total number of deaths from plague in Vladivostok amounted 
to 493 Chinese and 9 Russians, and among the latter were 6 persons belonging 
to the medical staff. 

discussion 
Participants: 

Dr. Wu Lien Teh 

Dr. Charles W. Young 

Dr. William H. Welch 

Dr. Wu: Both in the wards and in the postmortem room we used the two-tailed 
gauze and cotton mask, recommended by me and accepted by the International 
Plague Conference in Mukden, 191 1. Our staff wore goggles when in close contact 
with patients, but often this was impossible because of the moisture which would 
condense on the glass when entering a warm room from the outside cold (tempera- 
tures of — 15° to —30° C). In the postmortem room the operator wore two pairs 
of gloves so as to minimize accidents. The outer pair was boiled with instruments 
and pails, but the inner pair was simply disinfected with alcohol. 

Splenic punctures were performed with a short pointed knife which had been 
rubbed with tincture of iodine; this tincture was used also for the skin of the 
cadaver. From the blood thus obtained cultures were made direct on agar in 
addition to the usual slides. On all occasions, as few men were employed as possi- 
ble, and the technique was the simplest consistent with accuracy, because of the 
great danger to all concerned. 

The first case of plague appeared at Harbin on January 22, and the last was 
diagnosed on May 21. Our first complete postmortem was made on February 27, 



PATHOLOGY 



357 



and the last on May 21. Altogether forty-three postmortems were made, of which 
thirty-four were cases of plague. You will see from the table that practically all 
the early ones (up to May 13) were pulmonary in character, only four being 
septicemic, of which three were in babies under three years. After that date, all 
the ten cases except one showed purely septicemic features. This raises the ques- 
tion as to whether this preponderance of septicemic cases towards the end of the 
epidemic affected in any way its suppression. As I said in my address on Sep- 
tember 16, it is quite possible that the organisms passing through pneumonic 
cases were becoming so virulent that there was little or no time for the patients to 
develop pulmonary symptoms, and the medium of infection, namely the sputum, 
was therefore absent. As a consequence, the later victims became less infectious, 
though invaded by more virulent bacilli, fewer infections took place, and the 
epidemic gradually died out. • 

The accompanying table representing results from plague autopsies may be 
interesting: 





Male 


Female 


Total 


Remarks 


Pneumonic 


!S 


6 


21 


4 were of lobar type 
and of these, 3 were 
women. 


Septicemic 


10 


3 


•3 


All 3 female septicemic 
cases were under 3 
years. 



One unique case needs mention, that of a still-born infant whose mother was 
sent to the hospital for plague and gave birth to the baby six hours before she 
herself died. Postmortems were performed upon both bodies. The baby was full- 
term, and showed the following conditions: larynx and epiglottis — fine hemor- 
rhages throughout; both lungs — no air, but hemorrhages marked on pleural 
surface; pericardium — contained some blood; endocardium — showed endo- 
carditis, red points being visible on pulmonary valve; trachea and bronchi — 
some froth, but no blood; peritoneal cavity — full of blood-stained fluid; gall 
bladder — hemorrhage on surface; spleen, liver, and kidneys congested; placenta 
— showed plague bacilli, as did all the organs of the infant. Pure cultures were 
obtained from all organs examined, viz., heart, pericardial fluid, liver, spleen, 
lungs, pancreas, tonsils, kidney. 

The only bubonic case recorded in Harbin, out of 3,125, occurred in a pregnant 
Russian woman who had swellings in right femoral region. The baby born two 
weeks after was well. Hers was the only authentic case that recovered. 

The tongue, fauces, larynx, and trachea in almost all cases of plague pneumonia 
were congested, hemorrhages being frequently present. The trachea and bronchi 
were inflamed, pink, blood-stained froth in greater or less quantities being found, 
teeming with plague bacilli. 

With regard to pneumonia, the lobular form was more often encountered than 



358 



PEKING UNION MEDICAL COLLEGE 



the lobar. Where no pneumonia was present, the most intense congestion, often 
with hemorrhages, was the rule. Acute pleuritis was often marked but fluid was 
seldom found in the cavity. 

Owing to the belief among certain pathologists that the tonsils were the portals 
of entry in plague pneumonia, much care was taken by us to study these organs. 
Although hyperemia was present in almost every case, resulting in more or less 
enlargement, no special changes were observed, certainly none to justify one in 
believing that they were the portal of entry of the organisms. 

All other organs showed conditions usually encountered in cases of septicemia, 
though the changes found might be more acute than in other diseases. Certainly 
the liver often presented an appearance seen in acute yellow atrophy, yellow 
fatty patches being present which showed rapid degeneration of tissue. 

Two unusual facts were noted by us. As pointed out by Strong and Fujinami 
in 191 1, tuberculous subjects were seldom encountered in plague pneumonia at 
necropsy. Strong made twenty-five postmortems and failed to find any tuber- 
culous lesion. Fujinami recorded twenty-six plague autopsies and found only one 
case where the lungs were tuberculous. We made thirty-four necropsies on plague 
cases in 1921 and saw three cases of active tuberculosis, namely, one in the lung, 
one in the cervical glands, and one in the skin. We should, however, be chary 
about coming to any definite conclusion in the presence of such evidence. 

The second fact observed was the apparent persistence of the thymus in plague 
as well as in non-plague subjects. For instance our records showed the following 
facts : 





Plague Cases 


Non-Plague Cases 


Persistent 
Probably persistent 
Absent 


17 (60.7 per cent) 

10 (35-7 " ) 
1 (3-6 " ) 


1 (40 per cent) 

2 (40 ) 
1 (20 " ) 


Total 


28 


5 



The question of the survival of the thymus among the Chinese deserves investi- 
gation and I trust our anatomy and pathology colleagues will look into the matter. 



CONDITION AMONG TARABAGANS 



As pointed out in my address, we managed to produce experimental plague 
pneumonia in both the small Mukden marmot {Spermophilus citillus) and the 
large Mongolian marmot or tarabagan {Arctomys bobac). The specimens show 
that the changes in the organs are similar to those observed in human beings, the 
congested and hemorrhagic fauces, trachea, and lungs. In one animal which lived 
until the seventeenth day as a contact, when it was killed, white pea-shaped 
masses were noted all over the lungs, which showed under the microscope only a 
few Bacilli pestis. The presence of this subacute form of plague among these wild 
rodents will form an interesting study. (Since this demonstration was given, our 
staff has discovered a tarabagan sick and dead of plague in the wild state, con- 



PATHOLOGY 



359 



firmed later by bacteriological tests.) In the guinea pig specimen you will note 
the localized peritoneal abscess produced by first inoculating it with our spore- 
forming bacillus and then with Bacillus pestis. The animal lived until the seventh 
day, although the control did not survive twenty-four hours. The matter requires 
further elucidation. 

Dr. Young: There are two points to which I wish to call your attention. The 
first is the distribution of plague as worked out by Dr. Wu Lien Teh, especially 
from Russian sources. This is to be found in the First Report of the North Man- 
churian Plague Prevention Service (i). Dr. Wu points out that there have been 
frequent outbreaks of bubonic or pneumonic plague, or both, all the way from the 
Caspian Sea to Mongolia and Transbaikalia. The regions mentioned are Astra- 
khan Uralsk, the Kirghiz Steppes, and Semiretchinsk. Observations in Trans- 
baikalia and Northwestern Manchuria are also given. It seems clear that the 
whole region stretching across these arid highlands is an endemic center of plague, 
and from the fact that it occurs among nomadic or semi-nomadic peoples, it would 
seem likely that the source is a wild rodent. It was from this region that all the 
recent pneumonic epidemics have appeared. In articles on plague in books, 
Yunnan is usually named as the endemic center of plague. It is more likely that 
Yunnan is merely one edge of this great Asiatic endemic area. 

The second point is that there is in Li Hsien in Western Shansi a small, limited 
endemic center of bubonic plague, which antedates the pneumonic epidemic of 
1917-18, and in which no pneumonic plague occurred. Dr. Percy T. Watson of 
Fenchowfu, Shansi, has studied this area for several years. He tells me that the 
maximum incidence of the disease is in the late summer and autumn, and that he 
has observed a small pneumonic epidemic here, arising in November. It seems to 
me that this has great significance in view of the fact that all the pneumonic out- 
breaks of recent years in Eastern Asia have been winter epidemics. The relation 
of cold weather and overcrowding to the transmission of pneumonic plague is 
well recognized. The mortality in this area in Shansi has been very high — about 
96 per cent in one season. Dr. Watson is present, and I hope will give us an 
account of his observations. 

Dr. Welch: I recall very well the first outbreak of plague in San Francisco 
several years ago and the excitement caused by the announcement of Dr. Kin- 
yon's positive diagnosis. The picture of plague as it appeared in devastating epi- 
demics in the middle ages was before the minds of the people. The diagnosis was 
disputed and the issue figured prominently in the political campaign which was 
impending. One candidate for governor accepted the diagnosis and the other 
disputed it, the latter being elected — probably a unique instance of an effort to 
settle a scientific question by popular vote. 

Plague, as is well known, is primarily and essentially an epizootic disease of 
rodents, making under favorable conditions occasional excursions into the human 
host, where it appears in nearly all cases as the bubonic type of plague with little 
or no danger of conveyance from man to man. Experience has demonstrated 
extraordinary difficulties in eradicating the infection completely from the rodent 
population, but when the incidence in rodents is reduced to a certain point the 
danger to human beings under ordinary conditions of living becomes minimal. 
This is at present the situation among the ground squirrels in the infected area 



360 PEKING UNION MEDICAL COLLEGE 

in California, and I believe also among rodents in the county of Norfolk in Eng- 
land, and in many other parts of the world. It is impossible to say positively to 
what extent the seaports along the Gulf of Mexico and the Atlantic coast of the 
United States may harbor occasional plague-infected rats. 

I had the opportunity to see something of Dr. McCoy's interesting work in his 
plague laboratory in San Francisco where thousands of rodents, chiefly rats, were 
examined, and I was impressed with the wealth of pathological material pre- 
sented, only a small part of which was he able at the time to utilize. The discovery 
of the plague-like diseases due to other organisms, particularly that caused by 
Bacterium tularense, has become of much significance. 

The problems presented by pneumonic plague are in many ways different from 
those of bubonic plague, although there appears to be no ascertainable difference 
in the bacilli in the two types of the disease. A remarkable circumstance appears 
to be the failure of the occasional secondary pneumonias in the bubonic and the 
septicemic types of the disease to give rise to primary pneumonic plague in those 
who appear to be exposed, although the rare accidental laboratory infections in 
working with cultures have been pneumonic. Still the essential difference between 
the bubonic and the pneumonic types of plague appears to be the mode of infec- 
tion in each. 

Primary pneumonic plague in contrast with bubonic plague is among the most 
highly contagious and most uniformly fatal of human diseases, but by way of 
compensation and again in contrast with the latter it is a fairly controllable dis- 
ease. The campaigns against pneumonic plague in Manchuria, conducted by Dr. 
Wu Lien Teh, Dr. Strong, and their colleagues, and more recently in the prov- 
inces of Shansi and Shantung by Dr. Young and his co-workers, are among the 
most interesting and dramatic chapters in modern medical history. 

Dr. Wu's report at this conference of the inhibitory action upon the plague 
bacillus and its effects by certain spore-bearing bacteria is interesting and should 
lead to further study, especially as to its specificity, as it is well known since 
Buchner's experiments that foreign proteids of bacterial origin from various 
sources may influence the pathogenic effects of other bacteria. 

Those who have the opportunity should not fail to visit the museum of the 
Japanese Medical School in Mukden, where there is admirably displayed a unique 
collection of specimens of the Manchurian pneumonic plague. I was particularly 
interested when examining these specimens in 191 5 to note the characteristic 
lesions of the mediastinum and the mediastinal and tracheo-bronchial lymph 
nodes. A certain resemblance of these lesions to those found in some of the severe 
influenzal pneumonias at our camps in 191 8 may have given rise to the erroneous 
impression that there was some connection between influenza and genuine plague. 

May I be permitted just to call attention, a propos of my remarks the other day 
about the comparative study of epidemics, to the interest attaching in the solution 
of some of the problems of the spread of plague to the study of the habits of the 
people in their living, their working, their housing, their superstitions, even as 
affecting contact with animals, and the influence of the seasons upon living and 
housing habits. 

BIBLIOGRAPHY 

1. Wu Lien Teh, J. Hyg., 1913-14, xiii, 238. 



CASE REPORTS AND DEMONSTRATIONS 

By 

Henry E. Melenev, M. D. 

CASE I. THROMBOSIS OF THE SUPERIOR PETROSAL SINUS AND MENINGITIS, FOL- 
LOWING ACUTE MASTOIDITIS 

Meningitis and thrombosis of the venus sinuses of the dura are two of the com- 
plications which occasionally follow acute otitis media and mastoiditis. It is 
rather uncommon, however, for both these complications to occur in the same 
case, and it is still more uncommon for them to produce a clinical picture sug- 
gesting a localized brain abscess, and yet to present at necropsy no gross connec- 
tion between the original lesion and either of its complications. It is because of 
these unusual features that the following case is reported. 

History. An American missionary, male, aged twenty-two, was admitted to the 
Peking Union Medical College Hospital three weeks after having had his right 
ear-drum opened for an acute otitis media. Purulent discharge from the middle 
ear had persisted until the time of admission. Roentgen ray examination showed 
clouding of the right mastoid cells. Culture of the pus from the auditory canal 
gave only Staphylococcus albus. Temperature, pulse, and respiration were normal. 
There was a history of scarlet fever in childhood and a recent systolic blood pres- 
sure of 200 mm. Hg. On admission blood pressure was: systolic 148, diastolic 112. 
Heart was enlarged to both left and right, radial artery was thickened, urine was 
normal. White blood cells were 9,450 per cmm. 

Operation. A simple mastoidectomy was performed, removing granulations and 
inflamed bone from the right mastoid cells. Culture from the mastoid cells at the 
time of operation was sterile, but fifteen days later the discharge from the opera- 
tive wound yielded hemolytic streptococci in pure culture. Patient was discharged 
from the hospital seventeen days after operation, still having a slight discharge 
from the operative wound, but otherwise apparently well. Three days later he 
developed a severe headache localized to the left temple and was readmitted to 
the hospital. Headache was somewhat relieved by shrinking the turbinates. The 
next day he had a blotchy erythematous eruption over his neck and chest, his 
face was slightly swollen on the right side and was flushed. His neck was not rigid. 
Temperature was 38.5 C; white blood cells, 10,950; polymorphonuclear leuco- 
cytes, 61 per cent. On the fourth day after admission his headache became general 
and herpes labialis appeared. On the seventh day after admission the right eye- 
lid became slightly swollen and he complained of pain in the right eyeball. Eye 
grounds were normal. There was slight pain on flexion of the neck, but no definite 
stiffness. Spinal fluid was under increased pressure, and contained 14,600 cells per 
cmm., mostly polymorphonuclear leucocytes. No micro-organisms were found in 
direct smear or on culture of the spinal fluid. On the tenth day after admission 
the right pupil was larger than the left and there was a right internal strabismus. 
Coma developed. A subdural abscess in the right temporal region was suspected, 
on account of which the skull was trephined above the right ear, but exploration 
revealed nothing. The patient died that night. 

361 



362 PEKING UNION MEDICAL COLLEGE 

Necropsy was performed fourteen hours after death. On removing the calva- 
rium there was no excess of subdural fluid, but the brain pressed tightly against 
the dura. A pipette inserted into the right lateral ventricle obtained abundant 
cloudy yellow fluid, which, on culture, yielded hemolytic streptococci. The sulci 
of the cerebral cortex were made shallow by the internal pressure, and contained 
yellow purulent fluid, most abundant on the upper and lateral surfaces of the 
brain. At the base there was practically no exudate, except between the cerebel- 
lum and medulla where there was thick greenish-yellow pus. No abscess was 
found either within or outside the brain. After fixation the brain was sectioned 
and showed nothing grossly abnormal except congestion of the blood vessels and 
dilatation of the ventricles by cloudy fluid. 

The blood sinuses of the dura were all normal except the right superior petrosal 
sinus which contained a thrombus beginning at about its middle and extending 
mesially nearly to the cavernous sinus. It practically occluded the sinus, but was 
adherent only to the portion of the sinus adjacent to the temporal bone. At its 
lateral end it was organized and gray in color; in its mesial portion it was red and 
friable. Microscopically the organized portion was continuous with the sinus 
wall, and contained ouly a small area of fibrin. The unorganized portion con- 
tained many polymorphonuclear leucocytes, small groups of Gram-positive 
diplococci, and much necrotic fibrin. 

There was no gross opening from either the middle ear or the mastoid cells into 
the cranial cavity. The tegmen typani was intact. The typanic antrum was large 
and was connected by a large opening with the mastoid operative wound which 
was still open. The right middle ear contained only granulation tissue. The left 
middle ear and antrum, and the accessory sinuses of the skull were normal. The 
spinal cord was congested and surrounded by cloudy fluid, but there was no puru- 
lent exudate about it. The visceral organs were normal except for a mild degree of 
general arteriosclerosis, slight hypertrophy of the left side of the heart with thick- 
ening of the mitral valve, and cloudy swelling of the liver and kidneys. Culture of 
the heart's blood yielded hemolytic streptococci and Bacilli coli. 

This case illustrates the fact that no gross connection between the middle ear 
or mastoid cells, on the one hand, and the dural sinuses or the cranial cavity, on the 
other, need occur in order to produce a serious complication in either of these loca- 
tions. The tympanic cavity and antrum send small emissary veins into the 
superior petrosal sinus, and the lymphatics of these cavities are also connected 
with the walls of the blood sinuses and indirectly with the meninges. The menin- 
gitis in this case was probably produced by lymphatic extension of the infection. 
Whether the sinus thrombosis was of lymphatic or venous origin is more difficult 
to determine, but the fact that the oldest (most proximal and organized) portion 
of the thrombus was apparently sterile suggests that it was not a continuation of 
a septic thrombus in a tributary vein, but was possibly started by an inflamma- 
tion of the sinus wall borne from the middle ear or antrum by the lymphatics. 
Micro-organisms may have been introduced into the propagated distal portion 
of the thrombus either from the original source of the thrombus or from the 
blood-stream itself. The general bacteriemia which was revealed at necropsy 
may have arisen either from this septic thrombus or from the inflamed meninges 
by way of some other blood-vessel. 



PATHOLOGY 3 6 3 

_ A third feature of the case which is clinically important is the long period of 
time between the subsidence of the acute inflammation of the middle ear and 
mastoid and the development of the signs of meningitis. The case demonstrates 
that no case of acute mastoiditis or otitis media is free from the possibility of 
serious complication until the inflammatory process has entirely subsided, even 
if that be several weeks after the acute period of the disease. 

It is interesting to recall, in connection with the thrombosis of the superior 
petrosal sinus, the symptoms which were suggestive enough of an abscess beneath 
the temporal lobe to warrant an exploratory craniotomy. Nine days before death 
the right side of the face was swollen and red. Six days later the right eyelid 
became swollen and there was pain in the right eyeball. On the day of death the 
right pupil was larger than the left and there was right internal strabismus. 
Lesion of the third cranial nerve causes paralysis of the constrictor pupillse muscle 
and therefore dilatation of the pupil. Lesion of the sixth cranial nerve causes 
paralysis of the external rectus muscle and therefore internal strabismus. The 
ciliary branch of the ophthalmic division of the fifth nerve is the sensory nerve of 
the eyeball. Lesion of the fifth nerve might therefore produce a sensation of pain 
referred to the eyeball. Lesion of the superior maxillary division of the fifth nerve 
might also by reflex action cause vasomotor disturbances in the region supplied 
by it, and thus produce redness and swelling of the face and eyelid. Except for the 
paralysis of the external rectus muscle, which is the only possible evidence of 
lesion of the small sixth cranial nerve, the above symptoms are of the type which 
would be produced by a very slight injury or irritation of the nerves involved, not 
by complete loss of their function. In the present case the thrombosed portion of 
the superior petrosal sinus was in close proximity to these three nerves. It was 
directly above and close to the Gasserian ganglion of the fifth cranial nerve. The 
third nerve passed on the mesial side of it and the sixth nerve below and mesial 
to it. It is therefore possible that the same inflammatory process which caused the 
thrombosis of the superior longitudinal sinus, also existed about these nerves, and 
interfered with their function without producing a demonstrable local lesion in 
the bone or meninges. 

CASE 1. SYNCYTIOMA (ATYPICAL CHORIOMA) OF THE UTERUS, TERMINATED BY 

ACUTE PERITONITIS 

Chorioma, the interesting tumor developing from the ectodermal elements of 
the chorion of the fetus, is known to vary widely both in clinical course and in 
gross and microscopical appearance. In many cases it is an extremely malignant 
tumor, causing extensive local destruction of tissue and metastasizing widely by 
way of the blood-stream. In other cases, with the early clinical and microscopical 
appearance much the same, it is cured by curettage, or else spontaneously retro- 
gresses, occasionally even after the appearance of metastasis in the lungs or 
vagina. 

Even the earliest writers on chorioma, especially Marchand (i), recognized the 
great variation in the course taken by the tumor and the difficulty in determining 
from the histological examination either of curettings or of specimens removed at 
operation what the ultimate outcome would be. More recently, however, attempts 
have been made to classify the various forms of the tumor, (Schmauch (2), 



364 PEKING UNION MEDICAL COLLEGE 

Ewing (3), von Velits (4), R. Meyer (5) ), so as to determine, if possible, the 
criteria on which a surgeon could decide whether hysterectomy were required for 
a complete cure or whether curettage would suffice. Such a classification has not 
as yet been relied upon to any great extent, in determining surgical procedure, and 
is considered unreliable by some of the recent writers on the subject (Goff (6)). 
However, it is probably true that some definite law determines the benignancy or 
malignancy of all tumors, and it may be that eventually histological criteria will 
be found on which a differentiation of the benign from the malignant chorioma 
can be made. 

The elements which may enter into the formation of the chorioma are the cells 
of the two ectodermal layers of the chorionic villus, namely Langhans' cells and 
syncytium. Of these the Langhans' cells seem to be the element which has the 
power of destructive invasion and metastasis, while the syncytium apparently 
plays the role merely of an accomplice. Not all choriomas contain both elements, 
but they all contain syncytium. Some of those which contain both elements are 
benign in their course, some are malignant; but all of those containing only 
syncytium are apparently benign. 

The syncytium as it occurs in the tumors is often not a typical syncytium, but 
takes the form of large cells of various shapes, with deeply staining acidophilic 
cytoplasm and a single nucleus varying in size, shape, and staining property. 
Occasionally one cell contains two or three nuclei. That these cells are really 
derived from the syncytium is evident from their similarity to the true syncytial 
masses which are often present in the same tumor. The extraordinary thing about 
these cells is their apparent power of wandering from their original site through 
the tissue of the uterus, especially into the myometrium, where they are found 
singly or in groups between muscle cells, in the connective tissue, and especially in 
relation to blood-vessels. Often they bulge even into the lumen of a vessel, and it 
is probably their special tendency to do this that leads to the frequent metastasis 
of the tumor by way of the blood-stream. 

One of the striking facts connected with the benign choriomas is the frequency 
with which acute infection of the uterus accompanies the condition, often leading 
to a terminal septicemia or peritonitis. This feature is so common that some 
writers have called the condition "syncytial endometritis." The persistence in 
the recently pregnant uterus of soft, vascular, partly disintegrating tissue seems 
to provide an exceptional culture medium for bacteria which are accidentally 
present. The uterine wall, due to the presence of the tumor, remains abnormally 
vascular, absorption from the mucous surface is great, and the way is open for the 
formation of septic thrombi in the uterine veins or for the extension of the infec- 
tion to the peritoneal surface. 

The following case is reported to illustrate the septic termination which may 
occur in the presence of an insignificant and apparently regressing chorioma of 
the syncytial type. 

History. A female Chinese, aged thirty-five, was admitted to the Sleeper Davis 
Memorial Hospital, Peking, complaining of palpitation of the heart and weakness. 
Family and past history were irrelevant. She had been married at eighteen years 
of age and had had six children, the last one born three and one-half years ago. 
One year before admission she had a miscarriage, at which time she had a severe 



PATHOLOGY 365 

uterine hemorrhage, which recurred frequently thereafter until the date of admis- 
sion. Physical examination showed a poorly nourished and very anemic woman, 
with pulsating jugular veins, a systolic heart murmur heard over the precordium 
and over the left chest posteriorly, and a few moist rales at the bases of the lungs. 
Abdominal and vaginal examinations were negative. 

While confined to bed in the hospital uterine hemorrhage recurred without 
apparent cause. Temperature varied between normal and 100. 8° F. for the first 
three weeks in the hospital. At the end of this time there was only a scant pink 
vaginal discharge. She then had a sudden rise of temperature to 104 F., after 
which her illness took on a septic course, with temperature remaining above 
101 F. Eight days after the rise in temperature she complained of abdominal dis- 
tention, but had no abdominal pain. She sank rapidly and died that night. The 
final clinical diagnosis was septicemia. 

Necropsy was performed at the Peking Union Medical College eighteen hours 
after death. Externally the body showed extreme pallor and considerable ema- 
ciation. There were no petechial hemorrhages in the skin or mucous membranes. 
The thyroid gland was diffusely enlarged (a condition very common in Peking). 
The abdomen was distended and tympanitic. There was a slight pink vaginal 
discharge. The abdominal cavity contained about 500 cc. of gray purulent fluid, 
and the coils of the intestines were bound together by fibrinous adhesions. Culture 
of the peritoneal fluid and heart's blood yielded hemolytic streptococci. The 
uterus was slightly enlarged, measuring 8 cm. in length by 7 cm. across the 
fundus, and on being opened was found to have a rather large cavity containing 
a little purulent fluid similar to that in the peritoneal cavity. Smears from this 
fluid showed pus cells and many Gram-positive cocci in pairs and short chains. 
A culture was not made. In the uterine mucosa there were many small hemorrhagic 
areas. Otherwise the endometrium was pale, but was neither swollen nor soft. 
The myometrium was pale, firm, and not swollen. In the right cornu of the uterine 
cavity, just mesial to the point of entrance of the right Fallopian tube, was a 
flat, round, black and gray mass, 1.5 cm. in diameter, firmly attached by a 
broad base to the uterine mucosa, of very soft consistency, and with a gray, ap- 
parently ulcerated surface (Figurei). In the cervix were several small cysts con- 
taining clear fluid. In the uterine veins about the cervix and near the right fundus 
were several thrombi, apparently sterile. The lumen of both Fallopian tubes 
could be demonstrated grossly only in the outer third. Their fimbriated ends were 
red and edematous. The left ovary measured 5 by 1.5 cm., the right 4 by 1.5 cm. 
They were both flattened out behind the broad ligament. They each contained 
two small corpora lutea. The lungs were edematous and congested posteriorly, 
but showed no gross consolidation nor evidence of embolus. The spleen weighed 
I 75 g ra ms, was considerably enlarged and flabby and on section bright red and 
very soft. The kidneys were slightly enlarged, pale, and flabby, but otherwise 
grossly normal. At the hilum of the left kidney the renal vein contained a recent 
thrombus which completely filled it and extended into all the large branches of 
the vein. It did not, however, extend beyond the region of the kidney pelvis either 
toward the vena cava or into the left ovarian vein. The thyroid gland was en- 
larged and lobular and on section consisted of colloid glandular tissue and several 
large colloid cysts. The heart, aorta, liver, and other visceral organs were grossly 



366 PEKING UNION MEDICAL COLLEGE 

normal. The head was not opened. Microscopically the mass in the uterine cavity 
consisted of a thickening of the stroma of the uterine mucosa with entire absence 
of lining epithelium or glands, but containing scattered masses of smooth muscle. 
There were a few large blood vessels and very many small ones, especially capillary 
vessels dilated into sinuses. There was considerable infiltration by lymphocytes 
and a few polymorphonuclear leucocytes and, near the surface, many cocci which 
were not decolorized by the Gram stain. Scattered through this tissue were many 
huge cells of all shapes with one or rarely two nuclei of varied size, shape, and 
density, and with deeply staining, slightly granular cytoplasm. They sometimes 
reached one hundred micra in the longest diameter. These cells occurred both 
in groups and scattered singly through the tissue (Figures i, 3, and 4). They ap- 
peared to be easily distorted by the tissue in which they lay, conforming their 
shape to the requirements of the surrounding structures. Thus among the smooth 
muscle cells they often simulated huge cells of that type (Figure 5), and about 
blood vessels they shaped themselves to fit the lumen or coats of the vessel wall 
(Figure 6 and 7) . They were especially numerous about blood-vessels, sometimes 
abutting directly on the vessel lumen to the apparent exclusion of the endothelial 
cells (Figure 8). These cells were often found close together, but were not seen to 
be confluent like a true syncytium. In the myometrium beneath the tumor these 
huge cells also occurred in a few large groups as well as scattered singly in the 
smooth muscle or connective tissue or about blood vessels. They were present, 
however, only in the more superficial portion of the myometrium directly beneath 
the tumor, and were not found in any other part of the uterus than that immedi- 
ately adjacent to the tumor. 

The myometrium was normal except for the presence of the tumor cells. Its 
blood-vessels contained no thrombi. Sections from the remainder of the uterus 
showed loss of all of the surface epithelium and of some of the uterine glands. 
There was considerable infiltration of the superficial tissue by leucocytes, mostly 
mononuclear in type. There were also many Gram-positive cocci on the surface 
and in the tissue just beneath the surface. 

The Fallopian tubes microscopically showed nothing abnormal, each having a 
wide lumen near the outer end and very small lumen near the uterus. About the 
right tube, however, several vessels, whether veins or lymphatics it was impos- 
sible to determine, were packed with polymorphonuclear leucocytes and degener- 
ated cellular material. This was present in sections both from near the uterus and 
from near the fimbriated end of the tube and may have been the avenue of exten- 
sion of the acute infection from the uterus to the blood-stream and peritoneum. 
One small vein near the left tube contained a sterile thrombus. The other vessels 
were normal. The ovaries each contained several rather recent corpora albican tia, 
but none in the luteal stage, nor were there any lutein cysts of the type sometimes 
present in cases of chorioma. There were active ovarian follicles in various stages 
of development. 

The other organs showed only the changes incidental to a long illness termi- 
nated by an acute general infection. The thrombi in the uterine and renal veins 
were all sterile. 

The points of special interest in this case are: first, the insignificant and re- 
trogressing appearance of the tumor; second, its location close to the entrance of 



PATHOLOGY 367 

the right Fallopian tube; and third, the finding microscopically, of pus in vessels 
leading from this region toward the peritoneal cavity and the general circulation. 
Without the presence of the infection which terminated the case there is little 
doubt but that the tumor would have ultimately disappeared entirely. While 
still present, however, it was probably at least a portal of entry, through its 
soft necrotic surface, for the extension of the infection into the uterine wall. 
Without the presence of the tumor the infection of the uterine cavity might have 
been self-limited. 

The source of the uterine infection is not clear, but, with the parturient condi- 
tion of the organ prolonged by the presence of a portion of the embryo, a condi- 
tion existed which, especially in an ignorant person without medical attention, 
invited the introduction and growth of pathogenic organisms which may have 
been present in the vagina. 

The course of the disease in this case is the same as that which occurs in a con- 
siderable proportion of cases of syncytioma. In Schmauch's summary of 206 cases 
of chorioma (2) seven died of sepsis, and in all these the tumor was of the benign 
type. In some cases of this type as in Hammerschlag's fourth case (7) there is no 
definite tumor in the uterus, but the mucosa and muscularis are infiltrated by 
syncytial cells. 

This case illustrates the importance of establishing an early diagnosis of the 
cause of persistent uterine bleeding after abortion or parturition. It also illustrates 
the necessity of removing all possible tumor tissue in the presence of a chorioma, 
in order to avoid an unfavorable outcome from the extension of a possible infec- 
tion through the susceptible tumor tissue. 

I wish to express my thanks to Dr. Emma E. Martin of the Women's Union 
Medical College, Peking, for permitting me to examine and report this case. 

BIBLIOGRAPHY 

1. Marchand, F., Ztschr.f. Geburtsh. u. Gyndk., 1898, xxxix, 173. 

2. Schmauch, G., Surg., Gynec. and Obst., 1907, v, 259. 

3. Ewing, J., Surg., Gynec. and Obst., 1910, x, 366. 

4. Von Velits, D., Ztschrs.f. Geburtsh. u. Gyndk., 1905, lvi, 378. 

5. Meyer, R., Ztschr.f. Geburtsh. u. Gyndk., 1906, lviii, 98. 

6. Goff, B. FL, Am. J. Obst. and Gynec, 1921, i, 619. 

7. Hammerschlag, Ztschr.f. Geburtsh. u. Gyndk, 1904, lii, 209. 

EXPLANATION OF FIGURES 

Figure 1. Uterus and adnexa, showing syncytioma in right cornu of uterine 

cavity. Posterior view. 
Figure 2. Syncytioma. Syncytial cells in tumor near surface of uterine mucosa. 

X 5°- 
Figure 3 Syncytioma. Syncytial cells in myometrium beneath tumor. X 5°- 
Figure 4. Syncytioma. Another group of tumor cells in the myometrium. X 50. 
Figure 5. Syncytioma. Syncytial cell conformed to the shape of surrounding 

smooth muscle cells. X 1000. 
Figure 6. Syncytioma. Syncytial cells showing varieties of shape and of nucleus. 

X 250. 



368 PEKING UNION MEDICAL COLLEGE 

Figure 7. Syncytioma. Syncytial cells in the wall of an artery in the myome- 
trium. X 250. 

Figure 8. Syncytioma. Syncytial cells abutting on a blood sinus in the uterine 
wall. X 400. 

Figure 9. Syncytioma. Detail of syncytial cell. X 1000. 

Figure 10. Syncytioma. Another syncytial cell. X 1000. 




Autopsy 0IA-3Z. 



Fig. 1. 



.%■* -- 'fT'' ^'..'jc- ■■■- r .- 
















Fig. 4. 



Fig. 5. 



Syncytioma of the uterus (Figures I to 5) 



r *> ^ ."- 1 - -'^^i- 

»- '-' -,^ ... * Vasl^ 



^fctf* 






1 \ 



•"-TO? 



Fig. 6. 






Fig. 7. 



>-I 









^--*, . 



n-r*» 









'3 /"*^»if 



fw ■'• "* ' . *" if ,«•* ■••>•. 1 

'"^#\''« «,"■>> *■» •- "~ "'"^ v i V'-' 

Fig. 8. 

Fig. 9. Fig. 10. 

Syncytioma of the uterus (Figures 6 to 10) 



TETANUS 
Participants: 

Dr. Adrian S. Taylor 
Dr. George Y. Char 
Dr. Carl Ten Broeck. 
Dr. Johannes H. Bauer 
Dr. Samuel Cochran 
Dr. J. Preston Maxwell 
Dr. A. W. Tucker 
Dr. Theodore Tuffier 

Dr. Taylor: The occasion of this meeting is the incidence of tetanus in the 
Hsin K'ai Lu Hospital last fall, which I will briefly recount, and then Dr. Char 
will exhibit a case which he has under his care. 

Last fall a man came into the hospital with an old ankylosis of the hip with a 
chronic sinus. He was put in traction, the hip was put in plaster of Paris, and the 
deformity was largely overcome. He was in the hospital about a week or ten days 
when he developed tetanus and died, in spite of extensive antitetanic treatment 
immediately on the appearance of the symptoms. Over the sacrum was found a 
bed sore, and immediately over the wound there was a piece of felt contaminated 
with feces. We, of course, studied the case very intensively, and the results of 
that study have led to the meeting this morning. Dr. Ten Broeck will report the 
bacteriological findings. 

There have been during the last eighteen months in the Hsin K'ai Lu Hospital 
at least one or two other cases of death from tetanus from bed sores. I am sorry 
that through some fault in the indexing of the old histories we have not been able 
to find the case reports, but Dr. Korns remembers very distinctly at least two 
deaths from tetanus in the hospital, with bed sores, presumably with fecal con- 
tamination. That is a point we want to emphasize today — the importanceW 
fecal contamination in any wound in China. The work of Drs. Ten Broeck and 
Bauer will be along the lines of tetanus spores in the feces of Chinese. 

I will briefly recite the history of the boy who will be shown this morning. On 
the 27th of last April he fell from a height of about eight feet, striking upon his 
abdomen on a corner of a stove. He was brought into the hospital sixty-two 
hours later. At that time the abdomen was slightly distended, rigid, liver dullness 
was obliterated, and all the signs of a general peritonitis were present. Dr. Char 
operated immediately. He made a right rectus incision and found a ruptured in- 
testine with fecal contamination of the peritoneal cavity. He did an enterostomy, 
with drainage of the peritoneum, and the boy recovered promptly. About the 
tenth day after operation he was found to have a stiff neck and stiff jaws. He was 
treated immediately with antitetanic serum, intraspinally, intravenously, intra- 
peritoneally, and intramuscularly. We put a large amount of serum into the 
peritoneum, because we felt that was the source of the infection, and we put it 
into the muscles around the abdominal wound, for we felt that possibly the teta- 
nus infection had gone in through the wound. The boy recovered. 
25 3 6 9 



37o PEKING UNION MEDICAL COLLEGE 

Dr. Char: I reopened the wound about eight days after the first operation. 
The abdomen was so distended that it looked like a dilatation of the stomach. 
The lower abdomen was also distended, so that I thought it might be a case of 
temporary obstruction, and I reopened at the site of the rupture, so as to make a 
fecal fistula at the same time. I let the fistula go on until about June 28. Then I 
closed it and it healed. 

Dr. Taylor: Dr. Char did not mention that he did a tangential enterostomy. 
He simply sutured the edges together and closed the wound. 

Our part in this meeting is very small. We simply furnish the text for Dr. Ten 
Broeck. The feces of this boy were examined immediately, with positive results 
and four months later they still contained tetanus spores. 

Dr. Ten Broeck: I might say just a word about the bacteriology of these two 
cases. In the first case we were looking for the source of the infection. At first it 
seemed probable that it came from the felt; a great many cultures were made by 
Dr. Willner from the felt, and tetanus bacilli were not found. The bed sore, or at 
least the borders of the sore, were excised after the patient died, cultured, and 
tetanus bacilli were not found. The felt contaminated with feces, however, did 
contain tetanus spores, and it may be that if we had examined the base of the bed 
sore we might have found tetanus bacilli there. The results are not as clear as we 
should like to have them, for we did not get the organisms from the place where 
they were producing toxin. We got them only from the contaminated felt. In the 
second case we found the organisms in the feces soon after the boy came into the 
hospital, and also four months later. 

The first case made us wonder how commonly the gastro-intestinal tract of 
man contains tetanus bacilli. Going over the literature we found very few reports 
of positive findings. It is well known that earth, particularly street and garden 
soil, contains tetanus spores. It is also well known that the tetanus bacillus is 
probably a normal inhabitant of the gastro-intestinal tract of certain animals. In 
the cow the percentage is about 50; in other animals the percentage is lower. 
Park of New York says that in that city 10 per cent of the horses show tetanus 
spores in their feces. 

We have been able to find only two reports of tetanus spores in the feces of man. 
Pazzini, an Italian, some time before 1898, examined a number of Italian peasants. 
In the literature available to us the number of individuals examined is not given 
but he found that 5 per cent of these individuals showed tetanus spores. He also 
found that if he grouped his cases into those that had to do with horses, 30 per 
cent showed tetanus spores, whereas only 1.1 per cent of the others showed the 
spores. Tulloch of England has quite recently reported a very interesting study, 
which came to our attention after we had started our work. He examined the 
feces of overseas troops, soldiers recently returned from France, and found that 
22 per cent showed tetanus spores in their feces; whereas only 16 per cent of the 
civilians examined in England showed the spores. Of course these overseas men 
were living quite close to nature, as do so many of the Chinese. These are the only 
instances we have been able to discover of the finding of tetanus spores in human 
feces. There have been a great many investigations of the anaerobic flora of the 
gastro-intestinal tract of man, and I am sure that if tetanus were at all common 
in the gastro-intestinal tract of man at home we should have more reports of it. 



PATHOLOGY 371 

Dr. Bauer and I decided to examine the stools of Chinese for tetanus spores 
and requested that stools of patients recently admitted to the hospital be sent to 
us. A brief description of our method follows. A piece of feces the size of a pea is 
suspended in sterile salt solution and heated for thirty minutes at 80° C. to de- 
stroy the non-spore-bearing organisms. From this heated suspension a transfer 
was made to a Smith fermentation tube containing bouillon and sterile rabbit 
kidney. After four days' incubation films are made from the sediment in the fer- 
mentation tube and examined. If the organisms characteristic of tetanus are 
found they are obtained in pure form from the bouillon cultures in which they 
predominate by repeated transfers and anaerobic platings. Those of you who are 
at all familiar with anaerobic work will realize what a task this has been, and I 
think that Dr. Bauer deserves a great deal of credit for his persistence and his 
success in getting the cultures pure. After we obtain the organisms pure they are 
grown for ten days in fermentation tubes containing bouillon and tissue. The 
culture is then centrifuged and the supernatant fluid in a dilution of 1 to 1,000 is 
injected subcutaneously into each of two mice. At the same time two mice are 
injected with a mixture of 100 times this amount of culture (0.1 cc.) and approx- 
imately 1 unit of tetanus antitoxin. We do not call a culture tetanus unless it 
has the characteristic morphology and produces a paralysis in the mice receiving 
the culture alone while those receiving 0.1 cc. of culture plus tetanus antitoxin 
show no symptoms. 

We have examined the stools of seventy-two individuals and from twenty- 
four of these have isolated organisms which by the tests indicated above cor- 
respond to tetanus bacilli. In other words 33 P er cent °f the individuals examined 
showed tetanus spores in their feces. These figures are probably low, for we made 
only one examination of the stool of each person and at this time only a small 
portion of the feces was cultured. 

The examination of the charts of these patients shows us nothing of great 
interest. They were, with the exception of one foreigner, male Chinese with a 
variety of occupations and a variety of diseases. 

The question comes to one's mind, why is not tetanus more common if there is 
this great infection of the gastro-intestinal tract? Why do we not get it in tuber- 
culous ulcer of the colon or amoebic and bacillary dysentery? Why is it not more 
common in surgical cases? There is one explanation that may account for the 
comparatively few cases, and that is that carriers of tetanus bacilli may have an- 
titoxins in their blood. Examinations in Germany have shown that tetanus anti- 
toxin is not present in human blood, but Romer has found that the cattle showing 
tetanus bacilli in their gastro-intestinal tracts showed small amounts of tetanus 
antitoxin in their blood. It is possible that we have the same thing in man, and we 
expect to study this in the near future. I think you surgeons might consider the 
advisability of giving tetanus antitoxin in cases where there is possibility of infec- 
tion from feces, that is, where there are bed sores that may become contaminated, 
and in cases where you are going to do an intestinal anastomosis. 

There are two questions you might ask: one is, do foreigners show tetanus 
spores in their feces ? We have examined the feces of only one foreigner, and he 
showed tetanus spores. The other question is, why do these people not develop 
tetanus if they have tetanus bacilli in their feces? It has been shown a number of 



372 PEKING UNION MEDICAL COLLEGE 

times that tetanus toxin introduced by way of the stomach or rectum into the 
gastro-intestinal tract will not produce the symptoms of tetanus. 

Another question, and an important one, is whether tetanus bacilli multiply 
in the intestinal tract or simply pass through. I think most people incline to the 
view that the existence of tetanus bacilli in the gastro-intestinal tract is a purely 
accidental thing, this is, that the bacilli pass through without multiplying. We 
tried to get some light on this question by two ways of approach. One method 
was to examine the feces of patients who had been in the hospital for some length 
of time. We felt that the food in this hospital was practically free from tetanus 
spores, and asked that stools be sent us from patients who had been in the hospi- 
tal for a month or more. We received in all eleven stools. Three of these patients 
had been in the hospital between twenty and thirty days, and one showed tetanus 
spores. Eight patients had been in from thirty to fifty-nine days, and five of these 
showed tetanus spores in their stools. So that six of these eleven stools, or 54 per 
cent, showed tetanus spores in their stools. Of course this is a small series, only 
eleven cases, but the high percentage is rather startling. We have one patient who 
has now been in the hospital eighty-six days, who showed great numbers of teta- 
nus spores in his stools. I went into the data in regard to the food of these patients 
very thoroughly, and it seems to me that contamination of their food was practi- 
cally impossible. The rice they were given, which is their principal article of diet, 
and which might be contaminated, had been cooked under a steam pressure of 
50 pounds. It is not the policy of the hospital to use this high temparature but at 
present the steam reducing valves have not yet been received. Their bread also 
had been cooked under high steam pressure. The vegetables were washed im- 
mediately when brought into the kitchen, peeled, and then cooked for varying 
lengths of time — ten or twenty minutes. 

In one instance we have tried to estimate the number of tetanus spores per 
gram of feces as follows. We made a suspension of the stool, 1 gram to 10 cc. of 
salt solution, and heated it sufficiently to kill the non-spore-bearing organisms. 
From this heated suspension various dilutions were made and cultured, and we 
found that the highest dilution in which we could find the tetanus bacilli and 
from which we isolated the organism was 1 to 10,000. In other words, this patient 
showed 10,000 spores per gram of feces — a tremendous number. I think the only 
conclusion we can draw from these observations is that there must be a multipli- 
cation of tetanus bacilli in the digestive tract of man. It is not possible to take in 
so large a number of spores in the food given here in the hospital. 

To sum up, we can say that at least 33 per cent of the Chinese show tetanus 
spores in their stools and that tetanus bacilli probably multiply in the gastro- 
intestinal tract of man. I think it would be interesting to hear from some of you 
who are doing surgery here in China, as to how much tetanus you encounter which 
might be due to fecal infection. 

Dr. Cochran: This is a very interesting subject. I happen to come from a dis- 
trict where tetanus is excessively common — not so much in ordinary accidental 
or surgical wounds as in babies. I presume our soil is as thoroughly impregnated 
with tetanus germs as the soil of modern France was found to be. The ordinary 
technique of child delivery in our part of the country is somewhat crude. The 
usual method is to tie off the cord with a piece of ordinary string, and then to 



PATHOLOGY 



373 



pierce the stump with two pieces of kaoliang stalk, which comes in presumably 
from the cow house, and which is probably the source of infection. I have known 
at least two instances where seven children in succession in a single family died 
ten days after birth. The eighth child lived because of sterile dressings. The ques- 
tion of infection from the feces gives me much concern. I had a case of strangu- 
lated hernia in the hospital; I operated, and found the gut almost, but not 
quite dead. It was in such bad condition that I was doubtful whether or not I 
should do an enterostomy. I finally decided to resect it, and the gut did survive. 
The sac, however, was full of a turbid, ill-smelling fluid. About twenty days after 
the operation the patient developed a very mild attack of tetanus. We treated 
him in the usual way and he pulled through. Of course we were not in a position 
to make thorough bacterial examinations of the dressings and sutures, but as we 
had no other cases of tetanus from the same lot of dressings and sutures it is a 
reasonable supposition that they did not contain tetanus spores. I have wondered 
if there have been any similar cases. 

As Dr. Ten Broeck has said, it is an extremely interesting question why, with 
so large an amount of tetanus spores in the stools of the Chinese patients, we do 
not get more frequent infection. As a matter of fact, we have seen cases in which 
the wounds were soiled with feces, but with the single exception I have spoken of 
we have had no case of tetanus develop in the hospital. We have had tetanus 
from other sources, for instance, from the dressing of a compound fracture. I 
should like very much to hear from Dr. Ten Broeck whether he thinks there is any 
possibility of spores going through the intestinal wall. 

Dr. Ten Broeck: I suppose that if the wall is necrotic, or more or less necrotic, 
there might be a passage through it. I do not know of any work done on that 
question. I might say that a number of cases have been reported of tetanus in 
typhoid fever. 

Question: Can you say whether the tetanus bacilli sometimes lie dormant in 
the tissues, perhaps after the manner of the typhoid bacillus, and after the patient 
has quite recovered, some other injury may free the organism? I have had two 
cases. One patient received an injury of the finger, which healed perfectly but 
left a slight deformity. The finger was operated upon, and very shortly afterward 
the patient developed tetanus and died. The other patient was a boy whose hand 
had been crushed and some of the fingers taken off. He was brought into our 
hospital at Tsinanfu several days after the accident. His general condition was 
good. He was kept for a few days in the ward, the wound cleaned up, and a plastic 
operation was done. He developed tetanus; we gave him antitetanus serum and 
he recovered. 

Dr. Ten Broeck: It has been shown that the tetanus bacillus does lie dormant 
in the tissues. In fact there was so much tetanus following second operations 
during the war that orders were issued by the United States government and the 
English government that all cases that were to be reoperated upon should 
receive antitoxin. 

Dr. Maxwell: We had quite a number of cases during the war where tetanus 
occurred in skin operations — wounds that had been healed for months. In one 
case the wound had been healed for over a year. All cases were supposed to have 
had antitetanus injections. I should like to ask whether there was confirmation 



374 PEKING UNION MEDICAL COLLEGE 

of the late findings of the tetanus bacilli by animal infections. You have said that 
in the feces there were no other spore-bearing bacilli. I was surprised to hear that, 
for in some of the wounds we saw during the war there was a multiplicity of other 
spore-bearing bacilli, and it was difficult to tell which were tetanus and which 
were not. In fact we were not very well satisfied with the diagnosis. 

Dr. Ten Broeck: I think you misunderstood me. The gastro-intestinal tract 
is full of anaerobes. In fact the number of anaerobes probably equals the number 
of aerobes. We simply disregarded the others, confining our search to the tetanus 
bacilli. The organisms we have called tetanus have been isolated in pure cultures 
and have produced toxin, which is neutralized by tetanus antitoxin, the toxin 
producing the classical symptoms in mice. 

Dr. Taylor: Several men have asked me about the treatment of tetanus. Dr. 
Spourgitis spoke the other day of a case in which he used magnesium salts, but I 
cannot say that I know anything about its use. 

I understand that Dr. Spourgitis is using the magnesium chloride for its hyper- 
tonic action on the wound. Meltzer has published a paper on sulphate of magne- 
sium in tetanus, but it is too dangerous to use. Generally of course you can coun- 
teract the effects by calcium chloride given immediately, but you have too narrow 
a margin of safety — you may not give your calcium chloride quickly enough. T 
never use it. 

Question: I should like to ask if any of you have used carbolic acid. I have 
used it on several occasions, and have never seen any bad effects from it, and cer- 
tainly some cases improved. Whether they would have improved in any case I 
cannot say. But I always try it when I have no serum. I think a point to remem- 
ber is that you must give the carbolic acid until the urine becomes smoky. 

Dr. Taylor: The treatment with serum is a pretty serious proposition. Colonel 
Gray brought a patient into the hospital a few days ago following a gun-shot 
wound. He had already given the man $90 worth of serum, without great benefit. 
We contributed 25,000 units. We hoped to have you see the patient this morning, 
but he died yesterday. The boy who is shown this morning received 67,000 units. 

Question: Subcutaneously or intraspinally? 

Dr. Taylor: Intraspinally, intramuscularly, intraperitoneally, and intrave- 
nously. I think it is very important to know the incubation period of tetanus. 
The length of the incubation period varies inversely with the severity of the 
disease. 

Visitor: May I ask about carbolic acid. Was tetanus antitoxin used? 

Answer: Tetanus antitoxin was used. 

Visitor: I remember a case which was treated with carbolic acid and tetanus 
antitoxin. This case came to my knowledge in hospital practice in Chicago. A 
man employed in the stockyards fell and cut his nose, and two days later he 
developed tetanus and died. 

Dr. Taylor: I remember a case of delayed tetanus in Baltimore which inter- 
ested me — a patient with an osteomyelitis of the metacarpal bone of the first toe, 
who, sixty days after his discharge, developed tetanus, although antitoxin was 
given on the first admission. This patient recovered. 

Question: May I mention one thing that I think the war has brought out? 
It seems to me that after what we have heard this morning about the prevalence 



PATHOLOGY 375 

of tetanus in China it would be well to follow the lead of the armies in France 
with regard to prophylactic injections, and proceed on the supposition that it is 
our duty as practitioners here in China to give these prophylactic injections. I 
am interested in what has been said in regard to carbolic acid in tetanus. I come 
from a district where tetanus is very common. We have tried giving carbolic in- 
jections to infants — I should say we have given it to hundreds — and not one has 
recovered. But we gave carbolic acid injections to an adult patient in our wards 
who had tetanus, as there happened to be no antitoxin at hand, and that patient 
recovered, with, however, a paraplegia. I should like to know whether this is a 
common sequela of tetanus. 

Question: I should like to ask a question in regard to the dosage of the anti- 
toxin, because the second dose has very much less effect than the first, and if it 
should ever become necessary to give the same patient serum it would have much 
less power. Some people with diphtheria, for instance, prefer not to take the im- 
munizing antitoxin, because of the danger of sensitization. 

Dr. Tucker: In about two to three thousand accident cases a year we have 
one or two cases of tetanus. Most of those are street accidents. We think the 
incidence therefore is very low. 

Question: Is it true that donkey serum can be used? Following a previous 
disease where horse serum had been used would it be a safeguard to use another 
serum? 

Dr. Ten Broeck: I do not know whether donkey serum would be safe or not. 
Of course the donkey is quite closely related to the horse. The horse, is of course, 
the animal commonly used. If you give your patients tetanus antitoxin tell them 
they have had horse serum, and make them realize the importance of this, so that 
if they are subsequently treated with serum they can tell their next physician 
that they have had horse serum, and he can test their sensitivity and if necessary 
desensitize them. Now that so much serum is being given, it would be wise to de- 
sensitize all patients before giving serum. 

A member of the Conference, made the following report concerning the work of 
Dr. Roberts, pathologist in the Mayo Clinic: 

Even if you do not get an anaphylactic action when you give a second dose it 
takes about six or seven times the same amount of serum to produce the same 
immunity. Even when you do not get the anaphylactic action, you get the anti- 
toxin thrown off much more rapidly. So that I suppose if the second dose were a 
different animal serum you would avoid the rapid throwing off. 

Dr. Ten Broeck.: I think that if we ever develop serum work here we shall 
have to use an animal other than the horse, as practically all the horses here are 
infected with glanders. 

Dr. Tuffier: For preventive treatment of the wound I think that serum is the 
best thing. In the beginning of the war when we did not yet have sufficient serum 
we had many bad results, but when we had plenty of serum we did not have bad 
results, so I am sure that serum is a very good thing. Somebody has said that you 
have good results because you treat the wound immediately and not because you 
inject the serum — because you wash the wound and sterilize it. At the last meet- 
ing of the Surgical Congress the preventive serum treatment was discussed. It 
was never the same, for no two countries have the same technique. 



376 PEKING UNION MEDICAL COLLEGE 

Question: I should like to ask two questions. First, do you notice any effect on 
the occurrence of tetanus as the result of the substitution of human effort for 
animal effort in transportation; and further, whether you have had any expe- 
rience in treating tetanus by any other measure. I should like to know particularly 
about phenol treatment. 

Question: I should like to ask the question whether you have had cases of 
tetanus after dog bites, or things of that kind — donkey bites, horse bites, dog 
bites. Some cases I believe have followed the bites of dogs. We have had cases of 
hydrophobia, but, on the other hand, the symptoms of hydrophobia are really 
difficult to differentiate from those of tetanus. 

Dr. Ten Broeck: The phenol treatment has been discussed. I do not think, 
however, that any conclusions have been drawn. The cases have been compara- 
tively few. Some of the patients recovered and some died. I do not know that any- 
one here would recommend it. I do not quite understand the question in regard 
to the substitution of human for animal means of transportation. Do you mean 
would there be more tetanus or less tetanus with human means? 

Answer: I think there would be less tetanus. 

Dr. Ten Broeck: I think there is a great deal of tetanus here. The work re- 
ported earlier was that at least 33 per cent of the Chinese carry tetanus spores in 
their gastro-intestinal tract, and we know that the gastro-intestinal tract of man 
isjnuch like the gastro-intestinal tract of animals. 

Answer: Where I am living there is a large substitution of human labor for 
animal labor. In South China almost all the work is performed by human labor, 
and draft animals, except the water buffalo, are not common. Tetanus is very 
rare. A great deal of the work of pumping water and turning mills is performed by 
the water buffalo, and yet tetanus is very rare and I have been wondering 
whether the water buffalo is as commonly affected as the cow and the horse. I 
should like to mention one thing, and that is that the soil where there are sheep 
has been found to be contaminated with tetanus bacilli, and yet we have very 
little tetanus. I have not had more than fifteen cases in fifteen years. 

Question: This series was done here in Peking and had nothing to do with the 
water buffalo ? 

Dr. Ten Broeck: Yes, it was done here, and in other parts of China the results 
might be very different. I do not know anything about the gastro-intestinal 
tract of the water buffalo. It is quite possible that districts do vary. 



PATHOLOGICAL PROBLEMS IN THE ORIENT 

By 

William H. Welch, M. D. 

I regret that a meeting of the Trustees made it impracticable for me to take the 
place assigned on the printed program, and I appreciate the rearrangement which 
has given me this opportunity to speak at one of the conferences of the Patho- 
logical Department. 

I shall take the liberty of making the subject assigned to me by Dr. Mills — 
Pathological Problems in the Orient — somewhat incidental to certain general 
considerations concerning the organization and development of a modern depart- 
ment of pathology in China, particularly under the conditions to be found or to be 
created here in Peking. 

A few words by way of definition may not be out of place, obvious as they may 
be. Pathology in its broadest and strictly etymological sense is the science of 
disease and includes all of medicine except the art or the purely practical side, 
which aims to become the application of this science. A favorite text-book of 
pathology in its day, that of my old teacher, Professor Wagner of Leipzig, treated 
the subject in this comprehensive manner, including not only general pathological 
anatomy and pathological physiology, but also general diagnosis, general progno- 
sis, and general therapeutics. 

Less, however, from logical considerations than from practical, didactic neces- 
sity the term pathology has been more narrowly delimited so as to include on the 
one hand the morphological study of disease — gross and microscopic pathologi- 
cal anatomy — and on the other the study of diseased function or pathological 
physiology, especially from the experimental side. Etiological, especially bacterio- 
logical, chemical, and physical studies are important for both the morphological 
and the physiological sides of pathology. 

Virchow long ago — and here may I in passing call your attention to the great 
interest of his articles on this subject in the early volumes of his Archiv — 
pointed out that pathological physiology cannot be constructed solely from the 
laboratory or experimental side, important as this is, but rests upon the com- 
bination of experimental and clinical or bedside observations and studies. Thus 
you will not expect to find the whole of pathological physiology in such valuable 
text-books as Cohnheim's General Physiology (the appearance of which marked 
an epoch over forty years ago), and the more recent work of Krehl. 

There was a time when the interest of the pathologist was confined mainly to 
morphological or anatomical studies. Coming from the school of Cohnheim I was 
accustomed to emphasize in former days the narrowness of this conception and 
the importance of experimental pathology. I have always been proud of the 
development of this experimental side of pathology in my laboratory by Dr. 
MacCallum and other assistants who followed him, and the pioneer courses in 
experimental pathology, which have proved to be so useful and attractive. 

I always considered, however, that pathological anatomy is the central feature 
of a department of pathology, and the time has come when this needs to be em- 

377 



378 PEKING UNION MEDICAL COLLEGE 

phasized. With the development of bacteriology, of pathological chemistry, and 
of experimental pathology, each of which has its place in a pathological laboratory, 
there is real danger of the neglect of pathological anatomy. Nothing could be 
more mistaken than the view that this has contributed all that it is capable of 
doing to the progress of scientific medicine, and that its pursuit has no longer the 
interest and significance which it once had. 

I had already become somewhat apprehensive that a generation of younger 
pathologists was arising with little interest and little experience or training in 
pathological anatomy and histology, but keenly absorbed in the experimental, 
bacteriological, and chemical sides. The experience during the war confirmed 
this impression. Whereas there was no difficulty in finding bacteriologists for the 
laboratories attached to our camp hospitals, there was the greatest difficulty, 
amounting often to an impossibility, of finding in sufficient number pathologists 
competent to make proper autopsies, to write or dictate satisfactory protocols, 
to interpret the findings, and to preserve properly and work up the material ob- 
tained at autopsy. 

While I am sure that Dr. Mills and his colleagues here appreciate the impor- 
tance of autopsies and the cultivation of pathological anatomy in its broadest 
sense, you will allow me to call attention to the peculiar importance of such work 
here in China, where in the past autopsies have been so difficult to obtain and 
consequently so infrequent. Nothing is more disappointing in reading about 
diseases in China and in trying to form a conception of their nature than to find 
how unsatisfactory and meager are the pathological anatomical reports. Here 
there is certainly a rich field for the pathologist, so rich that one is justified in 
placing primary importance upon the making of autopsies and the careful study 
of pathological material as a function of this laboratory. It is gratifying to learn 
that the native prejudice against making autopsies is being gradually overcome, 
but doubtless much remains to be done in making the intelligent Chinese realize 
the essential part which pathological anatomy has played and will continue to 
play in the development of scientific medicine. 

In this connection permit me to say a few words about the status of bacteriol- 
ogy in the medical curriculum. The term itself has far outgrown its original 
significance, including as it does frequently other microscopic parasites, and also 
embracing not only systematic bacteriology, but highly specialized cognate 
subjects like immunity. Without dwelling on these subdivisions I should like to 
point out that historically bacteriology, as it relates to human diseases, has 
developed mainly either under the aegis of hygiene or of pathology, the former 
shelter being more common in Germany and the latter in America, each tending 
to certain special lines of development. There is no question that while bacteriol- 
ogy will continue to be cultivated in pathological and in hygienic laboratories, 
this branch of knowledge has won an independent position for itself, and its prog- 
ress is furthered by those who devote their entire time to its study. 

While recognizing this independent status of bacteriology, I conceive that there 
are distinct advantages in the present arrangement in this medical college, in its 
inception and for some time to come, in the close alliance between the teaching and 
study of bacterial and other parasites and the Department of Pathology. The 
arrangement should be of mutual benefit. In fact I see no objection and I see 



PATHOLOGY 379 

some convenience and advantage in the early development of this medical school 
in making pathology serve as a rather broad shelter for a number of subjects 
which may eventually claim their independence but which are all concerned with 
the laboratory study of the etiology and nature of disease and are in a logical 
sense divisions of pathology and may be so treated. 

It is not necessary for me on this occasion to dwell upon the great interest and 
importance of medical zoology in its threefold divisions of protozoology, hel- 
minthology, and entomology in the study and understanding of diseases of the 
Orient. Nothing is more commendable than the zeal with which not a few of our 
medical missionaries have pursued this subject, and the success which they have 
attained in spite of inadequate zoological training and material handicaps. The 
contributions already made in so short a time by Dr. Faust, the accomplished 
helminthologist of this College, are an augury of the rich harvest to be gleaned in 
this fascinating field. 

It may not be inappropriate to say a word about the task of making diagnoses 
for clinicians, especially surgeons, from specimens, often curettings, or other small 
fragments of tissue, removed for this purpose. This kind of work should be re- 
garded as a mere incident and not allowed to become a large part of the functions 
of a pathological laboratory. It is often most unsatisfactory, and at the same time 
it is responsible work, if the decision as to treatment is made to depend upon it. 
I would caution the inexperienced young pathologist not to hazard in any doubt- 
ful case a positive diagnosis and especially a definite prognosis; to learn all he can 
about the clinical features of the case; and to acquaint himself with the correla- 
tion between pathological findings and the clinical course. There are many pit- 
falls which can be learned only from experience. It may here be remarked that 
good surgeons nowadays rarely remove fragments of tumor merely for diagnos- 
tic purposes, as the consequent risks of metastasis have become well known. The 
merely diagnostic work of a pathological, as contrasted with a clinical laboratory, 
has become relatively inconsiderable in comparison with earlier days. 

I should like to say a few words, commonplace as they may seem to be, regard- 
ing the relations of teaching and of research in a medical school. It goes without 
saying that the primary purpose and obligation are educational. It is equally 
true in my judgment that research in various ways furthers this primary educa- 
tional purpose. As a rule the teacher who is interested in the study of problems 
presented by his subject, who is endowed with the spirit of investigation, is the 
most inspiring teacher. Such a teacher will find his problems and will find time 
somehow and without neglect of the instructional side to study them. While every 
good medical school endeavors to fill the important chairs with teachers of this 
kind, those with gifts of discovery of a high order are rare, and it is not to be ex- 
pected, perhaps not even to be desired, that every chair in a medical school should 
be so filled. Excellent service can be rendered by those whose gifts may not be 
conspicuous on the investigative side, who are interested mainly in teaching and 
the effective organization and conduct of the work of the department. The output 
of scientific work from a department is the greatest when many are attracted to 
work under a teacher who creates conditions favorable to the best kind of train- 
ing and the development of the scientific spirit. 

I am inclined to think that the development of independent institutes of re- 



380 PEKING UNION MEDICAL COLLEGE 

search has led some of our young men to a false perspective of the relation of 
teaching and research, which are historically so closely intertwined as to be insep- 
arable in institutions of the higher learning, and it would be a pity if this historic 
relationship were disturbed, and I am confident that it need not be. Do not think 
of teaching and of research as two entirely separate and distinct functions, one of 
which must be sacrificed to secure the other. Recall the many examples of great 
teachers who have also been great investigators. It is also well for the teacher to 
make sure of his special aptitudes, and if these are not in the field of research he 
should not force himself to follow a path to which he has not the clue. He may ex- 
cel in other ways which are of great service to the school. 

It is hardly necessary to remind you of the peculiar importance in this school 
designed to train Chinese students in modern medicine, of the objective method 
of study as exemplified by practical work in the laboratories and in the clinics. 
The methods and concepts of experimental science have been until recent years 
entirely foreign to the traditional educational system and habits of thought of the 
Chinese people. In this respect China has been in the condition of Western 
countries before the days of Galileo, Harvey, and Newton. With this traditional 
background it may not be altogether easy to develop those habits of close and 
accurate observation under natural and experimentally controlled conditions 
and of just inference from reasoning based on these observations upon which the 
method of natural science rests, but for the future of scientific medicine in China 
it is of the first importance that this be done. 

I hope that you will develop here a good museum of pathological specimens. 
That pathological department is fortunate which has attached to it someone, it 
may be an assistant, who is enthusiastic in the collection, preservation, and dis- 
play of pathological specimens which can be made to serve an important purpose 
in the teaching of students. 

The theme which has been assigned to me by Dr. Mills assumes that there are 
pathological problems peculiar to the Orient, and this is of course true. But I 
would remind you that these problems are not concerned solely with diseases 
which are peculiar to the Orient, interesting as they are. It is scarcely less in- 
teresting to study the influence of climate, of race, of housing, of cultivation of 
the soil, of food, of habits of living and working, and of other factors which might 
be specified, upon the occurrence and characters of diseases common to the Orient 
and other parts of the world. Much of this line of pathological and clinical study 
falls within what may be called comparative epidemiology or endemiology, and I 
conceive it to be a fruitful and fascinating field of investigation. 

Take such an excellent book as Jeffries and Maxwell's Diseases of China. On 
almost every page you will find some open problem. Why is kala azar almost con- 
fined to the natives, and sprue to the foreign population? I think that you have 
already found here that the statements in this book regarding the occurrence of 
typhoid fever in China need correction. There are impressions about infant mortal- 
ity, but how little is accurately known! Modern ideas regarding the development 
and the varieties of tuberculosis, modes of infection, the relation to what Colonel 
Bushnell calls tuberculization of the population and to infection in early life, the 
question of human and bovine tubercle bacilli, these and other questions relating 
to this ever interesting disease are clamoring for solution in this country. Here I 



PATHOLOGY 381 

might reinforce what I have already emphasized about the importance of patho- 
logical anatomical studies. It is such studies that have the last word to say on the 
vexed question of the relative importance and frequency of alimentary versus res- 
piratory infections, as may be illustrated by Opie's original and highly significant 
investigations of pulmonary tuberculosis. The universal use of human excrement 
as a fertilizer creates a number of highly important problems in hygiene and in 
pathology relating to hookworm and other intestinal parasites, typhoid fever and 
other diseases. How much is still to be learned concerning the various diseases 
caused by trematodes! The distribution of these diseases, which seems quite re- 
markable, the life histories of some of the flukes, and the pathological characters 
of these diseases are fascinating subjects of study. Malaria, amoebic and bacillary 
dysenteries, typhus, cholera, and plague are public health problems of great im- 
portance in many parts of China. There is still a mystery concerning some of the 
cases of splenomegaly, which do not seem to fall within any of the recognized 
categories. But I need not go on to enumerate problems with which you are more 
familiar than I am. 

I have tried merely to indicate that there is a wealth of interesting pathological 
problems of great local significance. Here is really the romance of medicine and 
you are to be envied the opportunities of attacking so many interesting and im- 
portant open problems. I would urge that in teaching and in investigating you 
keep before you these local problems, and do not settle down to just the same lines 
of work which you could pursue as well in Boston, New York, or Baltimore as in 
Peking. 

Your highest ambition should be to train Chinese students in modern, scientific 
medicine. Some of these will be practitioners, some teachers, and some investiga- 
tors, who will themselves contribute to the solution of such problems of their 
country as I have indicated, who will spread in their country the knowledge and 
the practice of the best that medicine can offer for the prevention and treatment 
of disease, and who will create new centers for education, investigation, and the 
care of the sick and injured. The consciousness that you are furthering this high 
purpose and thereby the health and prosperity of this great country, indeed of the 
civilization of the world, must be your supreme reward, and a very satisfying and 
enduring reward it seems to me to be. 



DEPARTMENT OF OPHTHALMOLOGY 



OPERATIVE CLINIC 
By 

Harvey J. Howard, M. D. 

CASE I. EXTRACTION OF CATARACT 

Hospital No. 718. A female Chinese, aged sixty-five. Vision began to diminish 
in right eye about two years ago; and in the left eye, a few months ago. 

Ocular Examination. 

Vision: O. D. Hand movements. No correction helps. 
O. S. -2.00 sph. = 6/60. 

Projection sense of both eyes, good. 

Ophthalmoscopic Examination. This showed an opaque lens and therefore no 
fundus reflex visible in right eye, and marked lenticular opacities in the left lens. 

Laboratory Examination. Urine and feces, normal. Wasserman, negative. 

Diagnosis. Mature senile cataract of the right eye, and incipient cortical cata- 
ract of the left. 

Operation. The so-called Smith-Indian operation is a method of intracapsular 
extraction of a cataractous lens. Colonel Smith, formerly of Amritsar, India, had a 
unique opportunity to develop a special technique because of the great number of 
his cataract cases, totaling about forty thousand in his term of about twenty-five 
years in India. Smith did not use a special forceps with which to pull the lens out, 
but applied pressure to the anterior segment of the eye by the use of a hook and a 
spatula to secure the expulsion of the lens. By virtue of an unparalleled experience 
and by the help of a marvelously clever Indian assistant, Smith proved to be 
eminently successful. Others who have tried his method have not been so success- 
ful. 

The advantage of extracting the lens with its capsule has, however, been quite 
universally recognized. Therefore other safer methods have been suggested and 
adopted. Kalt of Germany, Knapp and Verhoeff of America have used with suc- 
cess special forceps for grasping the lens capsule and pulling out the lens. 

An additional safeguard is the introduction before the operation is begun of a 
sclero-conjunctival suture, which is so inserted that it may be looped away from 
the field of operation, but may be pulled tight and tied, closing the lips of the 
wound at the end of the operation. There is a great tendency for many of the 
Chinese to squeeze at an inopportune moment during the operation. There are 
also cases who either refuse or are unable to remain quiet following a lens extrac- 
tion. In such cases the use of the stitch may save the eye. In one of our recent 
cases, a woman, the eyes were forcibly opened underneath the bandage after the 
patient awakened suddenly from a nap. Only the suture saved the eye from com- 
plete expulsion of the vitreous through the wound. In her case nothing untoward 
happened and all progressed well following a reapplication of a dressing and a 
bandage. 

Generally speaking the anterior capsule of a mature cataractous lens, which is a 
swollen lens with a comparatively tight capsule, is difficult to grasp with smooth- 

26 385 



386 PEKING UNION MEDICAL COLLEGE 

bladed forceps such as Verhoeff's or Kalt's. A sclerosed lens is also difficult or in 
fact impossible to remove by this method. The easiest lenses to remove are imma- 
ture cataractous lenses and Morgagnian cataracts. 

It was decided in this case to try to extract the cataractous lens in its capsule by 
the use of VerhoefF's extraction forceps. Failing this, it would be a simple matter 
to cut through or to remove a piece of the anterior capsule of the lens, and then 
extract the lens in the ordinary way. 

The right eye was properly prepared and cocainized for the operation. The first 
step in the operation was the insertion of the sclero-conjunctival suture after 
VerhoefF's method. The section was then made with a Graefe knife, and following 
this an iridectomy was done. The blades of VerhoefF's forceps were then inserted 
through the wound and three attempts were made to grasp the anterior capsule of 
the lens. This proved to be too resistant, so the forceps' blades were removed and 
Weeks' sharp-toothed forceps were used to tear ofFa segment of the anterior cap- 
sule. This released the swollen lens matter and the nucleus, which, with the aid of 
a lens spoon and a spatula, was successfully removed. The pillars of the iris 
coloboma were replaced by the spatula; the ends of the suture were drawn up 
and gently tied. There was no loss of vitreous and no other complications during 
or following the operation. 

Since the lens was not removed in capsule, the posterior lens capsule remained 
behind. This will become fibrous and will probably require a discission later on in 
order to produce a clear pupillary space. 

CASE 1. DISCISSION OF SECONDARY CATARACT 

Hospital No. 544. A male Chinese, aged ten. Vision began to diminish in both 
eyes about five years ago. This blurring steadily increased until the child was 
practically blind. He was first seen on August 11, ig2i. 

Ocular Examination. 

Vision: O. D. Hand movements. 
O. S. Hand movements. 

Projection sense was good. 

Ophthalmoscopic Examination. This showed both lenses to be opaque. 

Diagnosis. Juvenile cataract of both eyes. 

Operation. August 25, 1921. A combined extraction with insertion of sclero- 
conjunctival suture was performed on the right eye under chloroform with no 
complications. 

September 5, 1921. A linear extraction of the left lens was done under chloro- 
form with no complications. 

Diagnosis. Secondary cataract of right eye. 

Operation. Discission of the secondary cataract was performed under chloro- 
form. A good-sized elliptical pupil was made in the membrane, using Ziegler's 
knife needle. No complications. 

Discussion. The cause of the cataract in this child is unknown. It is not a case of 
congenital cataract, because the loss of vision did not commence until the child 
was five years old. We therefore call it a juvenile cataract in contradistinction to 
a senile or a pre-senile cataract. 

Cataracts in children very quickly become soft, because the lenticular fibers 



OPHTHALMOLOGY 387 

have not yet become sclerosed and consequently their degeneration is the more 
rapid. In the right eye a combined extraction was performed in the hope of re- 
moving the soft lens matter in its capsule; but the anterior capsule ruptured, re- 
leasing only a very small amount of straw-colored fluid, the entire contents of the 
capsule. It was not possible with the child under a general anesthetic to remove 
the capsule then without endangering loss of vitreous; so the eye was closed and 
the wound allowed to heal, with the idea that subsequently an incision through 
the capsule could be done with safety. 

With the experience of the right eye before us at the first operation, a simple 
linear extraction of the soft lens matter in the left eye was done. 



PRESENTATION OF CASES 

Participants: 
Dr. T. M. Li 
Dr. Harvey J. Howard 
Dr. W. S. Thacker-Neville 
Dr. P. S. Soudakoff 

CASE I. TOXIC AMBLYOPIA 

Dr. Li presented a case of a toxic amblyopia, admitted to the hospital on 
August 18, 1921, with a history of almost complete blindness coming on about 
three weeks before. 

History. The patient was a Chinese soldier, aged twenty-one. His body was 
covered with pox marks, caused by an attack of smallpox which he had had about 
two and a half months prior to the onset of the amblyopia. During the convales- 
cent period of the smallpox he took several doses of Chinese medicine, — one 
dose a day for eight successive days. Six or eight weeks after he had taken the 
Chinese medicine, he took six or seven green peppers with vinegar. The next day 
he noticed that his vision was somewhat blurred. On that day he took several 
more peppers and more vinegar. Following this the patient says his vision rapidly 
diminished, until about eight days after the onset he could scarcely see light. On 
the day following the second meal of peppers and vinegar he began to have a full 
feeling in his head, temporal headache, buzzing, and vertigo, which lasted for 
twelve days. No history of nausea or vomiting. 

Ocular Examination. Upon admission, August 18, the vision of each eye was re- 
duced to light perception; his pupils were dilated and immobile. The optic discs 
showed distinct signs of neuritis, the arteries were small and tortuous and the 
veins were engorged. In the right eye there was a slight hemorrhage around the 
superior nasal vein. 

Physical Examination. Spinal Wasserman test was negative; so were otolaryn- 
gological, dental, and X-ray examinations. 

Treatment. For two weeks he was given potassium iodide, 0.3 gram three times a 
day. Vision improved slightly up to counting fingers with the right eye at 18 
inches and with his left eye at 8 inches. 

On September 3 we began the hypodermic use of strychnine nitrate, ^ grain 
once a day. Vision increased up to the counting of fingers at 4 feet with the right 
eye and 3 feet with the left eye. 

Result. The optic neuritis disappeared, but the arteries were still somewhat con- 
tracted and the veins somewhat engorged. The discs were slightly pale, but not 
paler than is often seen in normal cases. 

CASE 1. QUININE AMBLYOPIA 

Dr. Howard reported a case of quinine amblyopia in the one-year old child of 
a missionary, who for a severe attack of the crescentic form of malaria had been 
given comparatively large doses of euquinine each day for ten days, and two doses 
of 0.15 novarsenobenzol, one on the third day and one on the ninth day. 

The physician in charge of the case on July 25, 1921, wrote Dr. Howard that 
"the coma, which began on the second day, continued for one week with gradual 

388 



OPHTHALMOLOGY 389 

improvement and regaining of consciousness. As soon as consciousness returned it 
was observed that the child could not see. The pupils were partly dilated and did 
not react to light. The euquinine has been given two days of each week for 
six weeks. The parasites were found in the blood for two weeks. No evidence of 
vision has yet been noticed. The child has gained in weight and strength and 
learned to walk alone. Small doses of potassium iodide have been started. 

The optic head seems to be white, the vessels rather small and there are small 
black specks on the choroid. It is difficult to get much with the ophthalmoscope 
in a small child. 

" I frequently see paralyses accompanying malaria, but they always clear up in 
a few weeks. When I see the cerebral symptoms in malaria as in this child, I give a 
poor prognosis." 

On July 29 Dr. Howard replied as follows: 

"I have come to the conclusion that you are dealing with a case of quinine 
amaurosis. I do not believe from your description of the case that the blindness of 
the baby is due to the malarial toxins producing papillitis or choked disc. In this 
latter case the atrophy which you see comes on late and there is also a marked 
tendency to hemorrhages on the disc and in the adjacent retina. In quinine amau- 
rosis the following symptoms are quite generally found: — total blindness in the 
beginning, pallor of the optic discs, diminution in the size of the blood-vessels, 
dilated and immobile pupils. There is generally associated for the first two or 
three days a tinnitus and a temporary deafness. Your description, with the excep- 
tion of the auditory symptoms, tallies very accurately with what I have outlined. 

"Prognosis: — Of all toxic amblyopias, those due to quinine generally have the 
greatest restoration. This restoration is confined at first to the central vision, 
which gradually widens. In most cases full peripheral vision is never restored. The 
color of the discs may remain white for months or even years but often turns to 
quite the normal color. Rarely is the blindness permanent. From what you have 
written, I am afraid that in this particular case restoration, if it occurs at all, may 
be only slight. At the same time, as I have stated above, there is more hope for 
these quinine toxic amblyopia cases than in any other type of toxins that we are 
acquainted with. 

"For treatment I advise the use of strychnine and digitalis. Nothing else has 
been found to be of value." 

The physician's reply of August 16 to Dr. Howard follows: 

" I wish to thank you for your letter of July 29 regarding the baby with quinine 
amaurosis. 

"About the time I received your letter the child began to show signs of return- 
ing vision. She now apparently sees clearly in all portions of the visual field." 

I mention this case because in China quinine amblyopia is not uncommon. 
Malaria in all forms is found quite generally throughout China, and some physi- 
cians report giving enormous doses of quinine to their severe cases. The wonder is 
that there is not more amblyopia in China caused by quinine. 

CASE 3. CHRONIC IRITIS 

Dr. Li reported a case of chronic iritis with acute exacerbations in which all 
examinations such as of tonsils, sinuses, teeth, and gastro-intestinal tract were 



39Q PEKING UNION MEDICAL COLLEGE 

negative. Blood Wasserman was also negative. But there existed an active chronic 
prostatitis. The iritis ran a very stubborn course until the prostatitis was actively 
treated. 

CASE 4. DIMINSIHED VISION AND VITREOUS OPACITIES 

Dr. Howard reported a case of diminished vision and vitreous opacities in 
which all examinations for the location of foci of infection proved negative except 
the X-ray examination of the teeth. This is a type of case often seen in China, 
perhaps proportionately as often among foreign residents as among the natives. 

DISCUSSION 

Dr. Howard: In Dr. Li's interesting case of retrobulbar neuritis which is before 
us (Case 1), we found great difficulty in getting a history complete enough to 
enable us to determine the probable toxic agent producing the amblyopia. 

From the history we knew it had no association with the patient's attack of 
smallpox, because the amblyopia came on suddenly several weeks after the attack 
was over. It did seem that it might have been the large doses of Chinese medicine 
which he took following the smallpox convalescence, but here again the patient 
says positively that the diminution of vision came on several weeks after he had 
taken it. 

We were finally able to secure from him the statement about his having eaten 
several green peppers and some vinegar on the day preceding his eye symptoms 
and again on the same day. He had probably eaten green peppers and vinegar 
before without any ill-effects, so he considered the incident at first too common- 
place to mention, until our resident physician made him refer back to each meal 
and tell all the things he had eaten. 

The suddenness and the severity of the amblyopia which has scarcely improved 
since the patient's admission to the hospital, and the fundus picture which showed 
a slight optic neuritis at the beginning, certainly made us think of wood alcohol 
poisoning, especially since he had headache and vertigo associated with the amblyo- 
pia during the first few days. But ordinary vinegar will not produce amblyopia, 
and a search of the literature failed to find any reference to amblyopia following 
the ingestion of peppers in any form. 

Our conclusion therefore is that the vinegar, which in China is often nothing 
more than diluted acetic acid, must have contained some methyl alcohol. It has 
been impossible to confirm our suspicions by an examination of the vinegar used, 
but in the complete absence of evidence of any other possible cause, it does seem 
as though our conclusions were correct. We have not seen in the past any toxic 
amblyopia cases that we could definitely attribute to methyl alcohol, but we have 
had cases of optic atrophy that came to the clinic long after suddenly becoming 
blind, and in several of them we had a strong suspicion that wood alcohol was 
the cause. 

Dr. Thacker-Neville: While in Salonika in 1 917 as a medical officer with the 
British Army, I saw hundreds of malarial cases; most of them were benign tertian, 
a few were malignant. 

My usual treatment consisted of putting the patient to bed and giving him 20 
grains of quinine three times a day for three days and then 10 grains three times a 



OPHTHALMOLOGY 391 

day for a fortnight or longer. However, I often resorted to intramuscular injec- 
tions, while a colleague of mine frequently employed intravenous injections of 7.5 
grains of quinine. Among these cases only once did I see quinine amblyopia. One 
patient who was receiving 60 grains a day developed quinine amblyopia about the 
fifth or sixth day of treatment. Later, in spite of injections of galyl and an intra- 
venous injection of 60 grains of quinine, the patient died of cerebral malaria. At 
the postmortem examination both spleen and brain were found to contain para- 
sites and crescents. Thus we see that a dose that was sufficient to cause amblyopia 
was not sufficient to kill the parasites. 

Dr. Soudakoff: Cases of toxic amblyopia, especially of methyl alcoholic origin, 
were frequent in Russia during the great war. Immediately after the declaration 
of war the sale of alcoholic drinks was strictly prohibited, excluding denatured 
alcohol, which could be bought for techincal purposes by license from the authori- 
ties. 

Denatured alcohol is ethyl alcohol made unpalatable by the addition of certain 
ingredients, one of which is methyl alcohol. But even the nasty taste of this com- 
bination did not prevent heavy drunkards from taking it sometimes in great 
quantity. From this group there were reported many cases of methyl alcohol 
poisoning, some of which were fatal. 

During my stay in Petrograd in 191 5 I had the chance of seeing several cases of 
methyl alcohol amblyopia in the Petrograd Clinic for Eye Diseases. Most of these 
patients had taken one to three glasses of denatured alcohol a day. After one or 
two weeks, rarely a month, they noticed marked impairment of vision, and then 
reported to the Eye Clinic. We found that the acuteness of vision was generally 
reduced to counting fingers at two or three meters. Usually the only change in the 
fundus was a pallor of the disc. 

The director and the chief surgeon of the above mentioned clinic, Dr. Blessig 
and Dr. Hermann, took a special interest in these patients and did their best to 
improve their vision. They tried injections of strychnine, and gave them drastics 
and potassium iodide, but unfortunately without any good results. 

The number of cases was so great that Dr. Blessig called an extraordinary meet- 
ing of the Petrograd Ophthalmological Association, where preventive measures 
were discussed. All the members present stated that they had not succeeded in 
producing even the slightest improvement in vision. 

I cannot tell exactly how many cases of amblyopia were registered in that clinic 
during my six months' stay there, but I am sure that at least one new case was 
registered every week. The average number of new out-patients amounted to 500 
a month. 



OPERATIVE CLINIC 

COMPLETE TENOTOMY AND RESECTION IN FOUR DIFFERENT 

TYPES OF STRABISMUS 

Participants: 

Dr. Harvey J. Howard 
Dr. T. M. Li 

CASE I 

An American medical missionary, male, aged fifty-three. Complained of moder- 
ate photophobia, headache more or less constant, and an occasional diplopia. 
Eyes tired very readily, especially when using them for close work. Recently had a 
small ulcer on left cornea, which healed without serious complications. 

Ocular Examination. Manifest refraction showed: 

Vision O. D. -|-.5osph.+ .25 cyl. ax. 150° = 6/4.5 
O. S. + .25 sph.+ i.oocyl. ax. i8o° = 6/6+ 3 

There was an exophoria of 4.5 and a right hyperphoria of 10° for distance and 
orthophoria for near. Associated-parallel-movements' tests revealed an under 
action of the left eye looking up and to the left. 

External examination showed a tiny centrally placed nebula on the left cornea. 
Ophthalmoscopy, negative. 

Diagnosis. Paresis of the left superior rectus. 

Operation. Complete tenotomy of the right inferior oblique was done following 
novocaine and adrenalin injection. An incision 12 mm. long was made through the 
skin of the lower lid opposite the orbital margin of the superior maxillary bone. 
Following the tenotomy the skin wound was sutured with three fine silk stitches. 

Result. The sutures were removed on the second day following the operation. 
Muscle balance tests with the eyes in the primary position showed that the hyper- 
phoria was completely corrected by the tenotomy. The lateral deviation was not 
appreciably affected. 

case 2 

A male Chinese medical student, aged twenty-three. Complained of headaches 
and frequent diplopia. 

Ocular Examination. 

Vision O. D. —3.00 sph. — .50 cyl. ax. 45° = 6/4.5-' 
O. S. —3.25 sph. — .50 cyl. ax. 180 = 6/4.5-! 

The patient was able to fuse, but only for a moment or two at a time. An exami- 
nation of the muscle balance revealed an esotropia of 20° and a right hypertropia 
of 20 for distance and an esotropia of 9° for near. Associated-parallel-move- 
ments' tests revealed multiple motor anomalies of both eyes, chief of which were 
a complete underaction of the left eye and a marked overaction of the right eye in 
looking up and to the left. 

Diagnosis. Paralysis of the left superior rectus and spasm of the right inferior 
oblique. 

Operation. Complete tenotomy of the right inferior oblique following novacaine 
and adrenalin injection. 

392 



OPHTHALMOLOGY 393 

Result. Two days later muscle balance tests showed the right hypertropia of 
2o° reduced to a right hyperphoria of i° only. The lateral deviation was practi- 
cally the same as before the tenotomy. 



DISCUSSION 



These two cases of tenotomy of an inferior oblique muscle represent a type of 
operation which has rarely been done. In the minds of some it is a radical proce- 
dure to cut a muscle of one eye, because a muscle of the other eye is paralytic or 
paretic. A decision to do so must, therefore, be based upon sound reasoning to 
have any justification whatever. 

Case i represented paresis of the left superior rectus producing a marked verti- 
cal deviation of the visual axes, which however was only latent, therefore fusion 
existed. In Case 1 there was no fusion, therefore a hypertropia which was associ- 
ated with an esotropia. The strabismus was a disfiguring one. 

In each case the purpose of an operation was to dimish or completely annihi- 
late the vertical deviation. This could best be done by producing the same sort of 
limitation in the associated antagonist of the paralytic superior rectus; i.e., a 
tenotomy of the right inferior oblique in each case was the only thing to do. It is 
true that the ability of both eyes to look up and to the left would then be distinctly 
limited, but this inability would be equal in the two eyes, or practically so. One 
patient has already learned to compensate for the diplopia induced by turning his 
head rather than his eyes, so for him the result will be the removal of the constant 
eye strain attendant upon overcoming the high degree of hyperphoria. 

case 3 

A female Chinese student, aged seventeen, with history of scar on the right 
cornea and a convergent squint of the right eye that occurred following an attack 
of smallpox in childhood. 

Ocular Examination. 

Vision: O. D. Counts fingers at 1 feet. No correction helps. 
O. S. +3.25 sph.-f.50 cyl. ax. qo° = 6/6+ 3 

A dense central opacity of the right cornea. No anterior synechia. Muscle 
balance tests were unsatisfactory, but for near sight there was at least 70 of eso- 
tropia. There were multiple motor anomalies, chief of which were a marked over- 
action of the right internal rectus and an underaction of the right external rectus. 

Diagnosis. Right esotropia caused by amblyopia exanopsia. 

Operation. For cosmetic purposes a complete tenotomy of the right internal 
rectus was done following local anesthesia. It was the intention to follow the te- 
notomy by a resection of the right external rectus, but the immediate result of the 
tenotomy was so nearly complete that it seemed wise to delay any further pro- 
cedure until the final result of the first operation was fully established. 

case 4 

A female Chinese teacher, aged twenty, with a history of convergent squint of 
the left eye since babyhood. 



394 PEKING UNION MEDICAL COLLEGE 

Ocular Examination. 

Vision O. D. + .25 sph.4-.25 cyl. ax. 90° = 6/7. 5- 1 
O. S. -f-i.oosph. =1/60 

Esotropia for distance of 25°, and for near of 35°; no hypertropia. Associated- 
parallel-movements' tests showed multiple motor anomalies of both eyes, chief of 
which were a marked overaction of the left internal rectus and a marked under- 
action of the left external rectus. 

Diagnosis. Left esotropia with amblyopia exanopsia. 

Operation. Resection of the external rectus and complete tenotomy of the inter- 
nal rectus of the left eye. It was the original intention to follow the resection of the 
left externus by a graduated tenotomy of the left internus, but it was found at the 
time of the operation that the latter procedure was insufficient, so a complete 
tenotomy was performed. 



INTERESTING CASES OF 1920-21 
Participants : 

Dr. Harvey J. Howard 

Dr. T. M. Li 

Dr. Henry E. Meleney 

CASE I. NEURO-EPITHELIOMA 

A female child, about two years old, was admitted to the hospital from the eye 
clinic on January 24, 1921, with a large tumor mass involving the eyeball and pro- 
truding from the right orbit, and with loss of vision of the left eye. 

History. The parents first noticed that the vision of the child's right eye began 
to diminish about five months prior to admission. The vision rapidly grew worse 
and finally the eye became totally blind. At this stage the pupil had a yellowish 
color. Two months later the eye appeared larger and protruded. Shortly after the 
eyeball ruptured and a tumor was then seen protruding from the ruptured globe. 
The tumor then grew very rapidly and the suffering of the child increased. Shortly 
after the tumor ruptured through the right eyeball, the parents noticed that the 
left eye was also losing its vision and that the pupil was becoming grayish in color. 

Ocular Examination. Examination of the right eye showed a tumor protruding 
from the orbit for about 5 cm. anterior to the orbital margin. Both lids were quite 
adherent to the tumor and were markedly stretched over the base of the tumor. 
The growth was nodulated, beefy red in color, bled when handled, and had a very 
foul odor. Signs of an eyeball could not be recognized, although a knob at the an- 
terior end of the tumor indicated the probable position of the globe prior to its 
disintegration. 

Examination of the left eye showed it to be sightless, with a widely dilated and 
immobile pupil through which a dirty yellowish irregular-shaped mass was seen 
with the unaided eye. With an ophthalmoscope, no red reflex was visible. The 
mass did not move and appeared to extend forward to about 4 or 5 mm. from the 
lens at its temporal border and to about 2 mm. at its nasal side. The surface of the 
mass was somewhat nodular. 

Physical Examination. Child had fairly good physical development, still being 
breast-fed. She appeared to be listless and in pain; was sallow and anemic looking. 
There were a few moist rales heard in the chest, due to the existence of a mild 
bronchitis. 

Laboratory Examination . Urine, normal. Blood examination: white blood cells, 
11,000; red blood cells, 4,976,000; hemoglobin, 35 per cent (Tallquist). 

Clinical Diagnosis. Neuro-epithelioma of both eyes. 

Operation. Total exenteration of the right orbit was done under ether. It was our 
intention to use radium as soon as the condition of the wound permitted, but the 
parents took the child home the following day and brought it back only twice for 
dressings, after which they did not return again. 

Result. From a personal visit to the child's home we learned that the child died 
about four months after the operation. The parents said the tumor had refilled the 

395 



396 PEKING UNION MEDICAL COLLEGE 

orbit and at the time of death protruded as far as the margin of the orbit. Death 
was probably due to glioma or neuro-epithelioma of the brain. 

Pathological Report. Dr. Henry E. Meleney 
Microscopic Examination. Sections all showed approximately the same picture. 
The tissue consisted almost entirely of tumor cells lying close together in a con- 
tinuous mass, and held in place by a very sparse connective tissue stroma. The 
tumor cells were of medium size, had oval vesicular nuclei and very little demon- 
strable cytoplasm. No definite fibrils were visible between the cells, but in places 
the cells were of spindle shape and their cytoplasm reached out to a pointed end. 
Mitotic figures were present in small numbers. There was a tendency to necrosis 
of tumor cells, sometimes at a uniform distance from large blood-vessels, some- 
times in little scattered areas not related to blood-vessels. In the necrotic areas 
some cell nuclei retained their staining property and shape. Here also was con- 
siderable brown pigment, probably from broken down red blood cells. There were 
no definite "rosettes," but in a few places cells were arranged radially about a cen- 
tral red mass containing several nuclei, not unlike a foreign body giant cell. Where 
the tumor had broken through the choroid of the eye a band of black pigment 
(melanin) was seen. The posterior sclerotic layer was also present as a hyalinized 
fibrous layer. One section showed the remains of an extrinsic eye muscle. 
Pathological Diagnosis. Glioma of retina. 

CASE 2. NEURO-EPITHELIOMA 

A female child, aged fifteen months, was admitted to the hospital from the eye 
clinic on August 14, 1921, with a tumor protruding from the left orbit. 

History. Parents first noticed when the child was three months old that its left 
eye could not see as well as the right. Shortly after, they observed a white spot in 
the pupillary space which grew larger and larger. Four months ago the child had 
an attack of smallpox which lasted for one month. After recovery the parents no- 
ticed a mass about the size of a small pea protruding through the left pupil into 
the anterior chamber. The tumor grew rapidly and finally ruptured the eyeball 
about two months before admission. From the time of rupture the mass grew with 
great rapidity, pushing the lid margins apart and protruding more and more from 
the orbit. On two occasions the mass was injured by falls of the child which caused 
profuse bleeding. The tumor has bled a little many times. 

Ocular Examination. The right eye was normal in every respect. No trace of the 
left eyeball was visible. Inplace of it there was a large tumor protruding for 3.5 cm. 
from the margin of the orbit. Its vertical diameter was 6 cm., its horizontal diame- 
ter 6.5 cm., and its maximal circumference 22 cm. It had a dirty red color, was 
somewhat irregular, and at several places had broken down and exuded a bloody 
fluid. The odor of the mass was very foul. 

Physical Examination. Child was well developed but sallow, still being breast- 
fed. No abnormalities except a weak and rapid heart-beat. Blood examination: 
white blood cells, 57,000; red blood cells, 2,592,000; hemoglobin, 45 per cent. 

Three days later, because the child seemed to grow markedly weaker, 200 cc. of 
blood (Group 4) were transfused intravenously. The general condition of the child 
considerably improved after the transfusion. Two days later, blood examination 



OPHTHALMOLOGY m 

showed: white blood cells, 29,800; red blood cells, 3,768,000; hemoglobin, 6c per 
cent. D * 

Clinical Diagnosis. Neuro-epithelioma. 

Operation. Two days after transfusion, total exenteration of the left orbit was 
done under ether. There was no evidence of tumor extension beyond this orbit. 

Result. For ten days the child continued to improve; it gained in weight and 
seemed playful and happy. Dressings were done daily. The child then developed 
nausea, vomiting, and high fever, grew rapidly weaker, and died in four days. 

CASE 3. GLAUCOMA 

Dr. Howard presented a case of absolute glaucoma of both eyes in which linen 
threads had been inserted for filtration and experimental purposes. Abstracts 
from the history follow: 

The patient was a male Chinese, aged fifty-nine. Symptoms of glaucoma came 
on in the left eye about two years ago, and in the right eye about a year ago. Both 
eyes became blind about three months ago. 

Upon admission on August 6, 1921, we found only the faintest perception 
of light in each eye. Tension taken with McLean's tonometer was O. D co and 
O. S. 80. 

Coarse linen threads were drawn through the anterior chamber close to the iris 
angle by means of a Graefe knife with a small hole in the blade for carrying the 
thread. The first procedure of the operation was to undermine the conjunctiva up 
to the limbus using the same method employed in a trephine operation. This was 
done on opposite sides of the cornea. The knife was then inserted beneath the un- 
dermined conjunctiva on one side, and into the anterior chamber, coming out with 
the counter-puncture beneath the undermined conjunctiva on the other side, the 
assistant holding the flap up in the meantime. The knife was pushed through the 
globe until the hole in the knife became visible, when the linen thread was put in, 
and then the knife was drawn back and out of the globe, pulling the thread after 
it. The two ends of the thread were cut within 2 mm. of their exits from the 
chamber. The conjunctival flaps were brought back and sutured securely so as to 
cover the ends of the threads. 

One of the threads could readily be seen lying across the surface of the iris in the 
anterior chamber, but the other thread was placed too close to the periphery of the 
chamber to be seen. During the past six weeks the tension has been taken on an 
average of every second day. The tension has ranged from 27 to 60 in the right 
eye and from 35 to 75 in the left eye. The tension during that period has been 
coming down. During the past week it has averaged 30 in the right eye and 45 in 
the left. 

DISCUSSION 

Dr. Howard: The threads were not inserted for the purpose of direct filtration 
as is done in Zorab's operation where silk sutures are inserted. Linen sutures were 
used because they are completely absorbed within a few weeks after being placed 
in living tissue. The question to be decided was whether, following the absorption 
of the threads, channels lined by endothelium were left behind. I knew that Dr. 
William Sharpe of New York had successfully produced drainage in hydrocephelus 



398 PEKING UNION MEDICAL COLLEGE 

cases by using linen threads in the brain, and if the drainage continued after the 
threads became absorbed it seemed obvious that some sort of open channels must 
have taken their places. With this in mind, while working with Verhoeffin Boston 
in 1918, 1 inserted linen threads in the eyes of rabbits. In less than two months the 
threads had entirely disappeared. The rabbits' eyes were enucleated and examined 
microscopically. No evidence of the threads remained; nor was there any evidence 
of filtration channels to be found. 

I felt, however, that the experiment should be tried upon a human being if 
possible, and selected a case in which there was as much hope for improvement 
by this method as by any other. It is too early to state anything definite about the 
linen thread method. Certainly the tension has been materially lowered in both 
eyes. The tension of the right eye has been within normal limits for the past two 
weeks, and the tension of the left is slowly coming down. There is distinct evidence 
that the thread which has been visible through the cornea is being absorbed. In 
another month I should expect it to disappear entirely. At that time our conclu- 
sions should be more definite as to the value of the method. 



OPERATIVE CLINIC 

THREE CASES OF EXPRESSION FOR TRACHOMA 

Participants: 
Dr. Harvey J. Howard 
Dr. T. M. Li 

CASE I 

A male Chinese clerk, aged thirty. 

Diagnosis. Chronic trachoma of both eyes and partial ptosis of the right upper 

Operation. Heisrath's resection of the tarsus of the right upper lid. 

CASE 1 

A male Chinese medical student, aged twenty-six. Had a chronic trachoma for 
years, for which he had been treated in another hospital. All signs of an active 
trachoma had disappeared, but the palpebral conjunctiva showed many scars and 
the lids many wild hairs. 

Diagnosis. Trichiasis of both upper lids. 

Operation. Modified Streatfield-Snellen operation was performed on both up- 
per lids. 

case 3 
A male American child, aged five. 
Diagnosis. Follicular trachoma of both eyes. 

Operation. Expression of the contents of the trachomatous follicles of both eyes 
under ether anesthesia. 

DISCUSSION 

Dr. Howard: Cases i and i are trachoma in the third or final stage. Fortunately 
they have escaped with the cornea of each of their eyes in fairly good condition. 
The scar tissue formation in the conjunctiva, however, has produced a thickened 
deformed tarsus and a partial ptosis in one case, and a growth of wild hairs in the 
margin of the upper lids of the other. 

In the first case a removal of most of the tarsus through a double elliptical inci- 
sion in the conjunctiva of the upper lid was done. Mattress sutures, which also 
held in position the lower ends of the levator muscle fibers, were put in through the 
lid. 

In the second case a plastic operation of the upper lids was done for the purpose 
of deviating the course of the wild hairs. The modified Snellen operation has with 
us proved to be the quickest operation and one whose results are excellent. 

In Case 3 the disease was still in the first stage. Therefore there was no involve- 
ment of the cornea or deformity of the lids. The problem was to eradicate the dis- 
ease from the conjunctiva. In our experience we have found that an expression of 
the contents of the trachomatous follicles, with as little traumatism as possible, 
greatly hastens the cure. Following such an operation there should be daily rub- 
bings of the diseased lids with mercuric chloride 1-500 and boric acid powder. 
These remedies are applied with pressure by toothpick swabs. The use of zinc sul- 
phate in 0.25 or 0.5 per cent solution is advised several times a day. Treatment in 
such cases will probably have to be continued for four or five months. 

399 



PRESENTATION OF CASES 
Participants: 

Dr. Harvey J. Howard 

Dr. T. M. Li 

Dr. George E. de Schweinitz 

CASE I. TUBERCULOUS UVEITIS OF BOTH EYES. DR. HOWARD 

A male Chinese, aged seventeen, a pork-seller's assistant, was admitted to the 
hospital August 12, 1921, complaining of blurred vision of both eyes. 

History. His family history and past history were negative. There was no history 
of injury. He first noticed about one month ago that his right eye was red. A few 
days later the vision of that eye became blurred. This blurring steadily increased. 
The left eye became affected in the same way five days ago and the vision steadily 
diminished. 

Ocular Examination. 

Vision O. D. Hand movements. 
O. S. 6/20. 

There was moderate circumcorneal infection of both eyes, but no other involve- 
ment of conjunctiva and none of the sclera. The cornea of the right eye was very 
hazy from a general parenchymatous keratitis; the left eye was only slightly so. 
On the lower posterior surface of the right cornea were a dozen or more discrete 
milky spots or deposits resembling mutton fat droplets, varying from 0.5 to 2 mm. 
in diameter. On the posterior surface of the left cornea there were numerous fine 
deposits which had not become discrete. 

The iris of each eye was dull in color, and the pupils were slightly irregular, but 
there were no synechias. The pupils reacted to light and accommodation, but the 
right one only sluggishly. Tension with the McLean tonometer was O. D. 45, 0. S. 
28. No clear fundus reflexes could be obtained, the media of the right eye being the 
more cloudy. 

Physical Examination. General physical examination negative. Examination of 
teeth and accessory sinuses was also negative. 

Three diagnostic subcutaneous tuberculine tests indicated the presence of an 
active tuberculosis. Wasserman test proved to be positive, + + . 

'treatment. During the past four weeks the patient received three doses of 
arsaphenamine and three therapeutic injections of old tuberculine. In addition he 
was given atropine instillations, and hot compresses for his eyes, and potassium 
iodide by mouth. 

Result. The haziness of the cornea almost completely disappeared (September 
22), the deposits on the posterior corneal surface changed from day to day, but 
tended to gather around the periphery, leaving the central area practically free. 

It was possible to see that the vitreous of the right eye was filled almost com- 
pletely with massive opacities. The vitreous of the left eye was quite cloudy, and 
contained large membranous opacities, but the details of the disc and vessels could 
be made out fairly well after the eye had been kept quiet for a few moments. The 
vision of the eye had not improved since admission. 

400 



OPHTHALMOLOGY 401 

Diagnosis. The diagnosis of the cause was the double infection of tuberculosis 
and syphilis. The tuberculous uveitis was probably aggravated by the general 
luetic infection. 

CASE 2. PRIMARY OPTIC ATROPHY. DR. LI 

A male Chinese, aged forty-five, complained of blindness which began to come 
on about a year ago. Admitted both syphilitic and gonorrheal infections twenty 
years ago. 

Ocular Examination. Vision of both eyes was reduced to faint light perception. 
Pupils were semidilated, round, and did not react to light. Ophthalmoscopic exami- 
nation showed that the media were clear, the disc margins regular and sharply 
defined, the disc surfaces had a distinct grayish pallor, and the arteries were con- 
tracted. 

Physical Examination. The spinal fluid Wasserman was positive, + + + + • 
Dental examination revealed the presence of several abscessed roots. These roots 
were subsequently extracted. 

Diagnosis. Primary optic atrophy due to syphilis. 

The presentation of these cases was followed by an informal discussion by 
Dr. George E. de Schweinitz of some newer aspects of uveal tract disorders and 
therapeutic measures for their relief. 



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DEPARTMENT OF OTOLARYNGOLOGY 



OPERATIVE CLINIC: ESOPHAGOSCOPY 
By 

A. M. Dunlap, M. D. 

History. Male Chinese, aged sixty-four. Complaint, difficulty in swallowing 
solid food. Duration, about two months. There was considerable loss in weight 
and strength. On three occasions there was vomiting about two minutes after eat- 
ing. Had had occasional pain in region of the stomach. Was able to take liquids. 

Physical Examination. Fluoroscopic examination showed incomplete constric- 
tions of the esophagus above the level of the ninth thoracic vertebra. The outline 
of defect was ragged, suggesting carcinoma. 

Operation. Dr. C. Jackson does most of his esophagocopies under cocaine, rarely 
ever using ether. In an old man such as this patient we should look for a stricture, 
caused by malignancy, and I suspected that was what we should find. A 11" 
Mosher esophagoscope was introduced down past the esophageal opening behind 
the larynx. It was inserted with a mandrin until it was below the pharynx. The 
mandrin was then withdrawn and the tube pushed down gently, always with the 
end of it in view, to avoid the danger of going into fragile tissue. The Jackson eso- 
phagoscope is much smaller andmuch easier to insert, but in using this instrument 
it is much more difficult for the average individual to observe what is on the 
other end. 

Jackson (1) makes a statement that no one should attempt to remove foreign 
bodies from the esophagus until he has performed the operation at least 100 times. 
(Dogs are generally used.) Thus far our College has not used dogs, but I think now 
that we are to have a laboratory we should do dog work. In the dog we meet with 
very much the same condition as in man, except that the larynx is straight down. 

In the present case the esophagoscope was slowly introduced for its entire 
length. Only normal esophagus wall was demonstrated. Location of the aortic 
arch was demonstrated. The 12" esophagoscope was withdrawn and a 15" instru- 
ment was then introduced. Suction was used to clear the field of fluid. A small 
tumor mass was found on the posterior wall of the esophagus, which partially ob- 
structed the lumen. Grossly this tumor appeared to be a fairly advanced ma- 
lignant growth. With a biting forceps a small portion of the tumor was removed 
for examination. This was followed by slight bleeding. 

The difference between the blocked esophagus and the normal smooth esopha- 
geal wall above the constricting tumor was demonstrated. 

The esophagoscope was gently removed. 

Demonstration of the use of Mosher's laryngoscope followed. 

BIBLIOGRAPHY 

I. Jackson, C, Peroral endoscopy and laryngeal surgery, St. Louis, 191 5. 



405 



OPERATIVE CLINIC: RADICAL MASTOIDECTOMY 

By 
J. Hua Liu, M. D. 

History. Patient complained of purulent discharge in left earwhich had lasted for 
twenty-five years. Had had no previous nose or throat trouble. At age of seven 
had had painful swelling over the left mastoid region, which suppurated after ten 
days. After that time there was a discharge daily from the wound, which lasted 
for more than a year, after which time the wound healed gradually and the dis- 
charge stopped. After the discharge had ceased from mastoid region, patient 
noticed a foul discharge from the ear on that side, which lasted up to time of ob- 
servation. Had had headache and dizziness previously for a few days. No fever. 

Physical Examination. Right ear normal. Left ear-auricle and external auditory 
canal in good condition. Tympanic membrane was gone and the promontory was 
covered with granulations, considerable discharge in the canal. Old scar was seen 
over upper portion of mastoid region. No mastoid tenderness. 

The radical mastoid operation has for its purpose the union of the external audi- 
tory canal, the middle ear, antrum, and the mastoid wound into one cavity, ca- 
pable of being drained without interference. 

The radical mastoid operation was called for in this case principally for six rea- 
sons: 

i. Long duration (twenty-five years). 

2. Did not yield to treatment. 

3. Tympanic membrane gone, with malleus and incus necrosed away. 

4. Granulations on promontory. 

5. Loss of hearing. 

6. History of acute attack twenty years ago. 

Operation. Iodine preparation of the area. The usual post auricular incision was 
made down to the bone, except at the uppermost portion, where it was inadvisable 
to cut through the temporal muscle. The periosteum was then lifted and retracted, 
exposing the cortex. The landmarks were then visible. Here was the bony canal 
which was just internal to the anterior retracted flap with the spine of Henle just 
below its superior margin. The latter indicated the level of the antrum. As a rule 
chisels and gouges are used to remove the cortex of the mastoid, although some 
operators use burrs. In the present case we found the mastoid was of the sclerotic 
type, which had no cells. I then saw a cavity which was filled with cholesteatoma 
communicating with the antrum. The antrum and the mastoid cavity were made 
as large as possible. 

In clearing out the uppermost and posterior portions of the mastoid process one 
has to be very careful not to expose or injure the dura nor the lateral sinus. In the 
manipulation of the antrum, caution should be exercised to avoid injury to the 
antral mucosa and to the horizontal semicircular canal which lies in the floor of 
the antrum. The posterior canal wall was now removed by chisels. The bridge was 

406 



OTOLARYNGOLOGY 407 

then removed. During manipulation in this region, the anesthetist must keep 
watch over the corresponding eye and lip, and must give warning of any twitch- 
ing which indicates that the operator is working near the facial nerve. In view of 
the danger of recurrence of infection through the Eustachian tube, and the in- 
terference with healing, the latter lumen was obliterated by Yankauer's curettes. 

Plastic Flaps 

Question: Supposing you do not make a flap? 

Answer: The purpose of the flap is to provide a sufficiently wide opening for 
dressings and drainage through the external auditory meatus and to encourage the 
growth of an epithelial covering over the cavity. Incision is carried from within 
outward toward the lower conchal margin, then a round flap is cut out of the 
concha so that the incision ends at the canal margin. The cartilage of the concha 
exposed by the flap is removed and then the flaps are sutured. The cavity is loosely 
packed with iodoform gauze strips through the external auditory meatus and the 
postauricular wound sutured without drainage. 



OPERATIVE CLINIC: REMOVAL OF TONSILS AND ADENOIDS 

By 

A. M. Dunlap, M. D. 

I had planned to show the different methods used in the removal of tonsils, but 
as too often happens in China, the patients did not put in their appearance; but I 
was able to demonstrate the so-called Boston method as to technique of operation 
and position of the patient. 

This position may be criticized by some as being one which is somewhat dan- 
gerous, due to the upright position. There is no doubt about the recumbent posi- 
tion being an ideal one if you can do just as good an operation. In the upright posi- 
tion you must always be sure never to have your patient so deeply under ether 
that his reflexes are lost. In Boston, the upright position is used because it is a 
normal one. Of course it has its disadvantages. When statistics were taken a few 
years ago, it was not felt that there was any more danger from the upright position 
than from the recumbent one. 

When the soft palate is touched and the patient gags, you know he is not com- 
pletely under. You must have relaxation if you are going to do a proper operation. 
Be sure you have a good tenaculum which will grip the tonsil and will hold. The 
tonsil is located in a sort of box, — in front, the anterior pillar formed by the palato- 
glossal muscle; behind, the posterior pillar formed by the palato-pharyngeal 
muscle; to the outer side, the broad muscle of the pharynx. This can be pushed 
outwards, without going through the large vessels nearby, if the tissues are 
healthy. In children we find a great deal of stimulation of the glands. This mucus 
and saliva can be bailed out as the larynx is always under control. 

The patient under operation was in a condition to cough up anything entering 
the larynx. The method of removing the tonsils employed in this case is called 
the snare method. I did not want to enter the pillar. I incised the plica, that is the 
fold of mucous membrane which was reflected from the pillar to the tonsil. 

Going through the single layer you get directly on this white glistening mem- 
brane which is the capsule of the tonsil. Get the capsule of the tonsil complete and 
then do not worry about the tonsil. Before removing the tonsil from the tenaculum 
you follow it around and see that you have the capsule intact with no breaks. 

Question: Supposing there were breaks? 

Answer: Go back with the tenaculum and snare. Ten years ago we used not to 
be very anxious about a certain amount of bleeding, but now a patient is never sent 
away from the operating room with any signs of bleeding. 

You can see that this fossa is perfectly clear. 

We rarely, if ever, make a tie. However, when a tie is made, we use silk or catgut. 
When necessary we use hemostats to clamp the bleeding points for a few minutes. 

Successful removal of the tonsil depends upon getting good hold with the tenacu- 
lum and dissecting the capsule, without going through into the tonsil. If you 
watch, you will see that the end of the snare canula travels behind the tonsil thus 
showing what dissection is, if any, lacking. I always put the snare canula above 
the tonsil. You must be careful not to get your uvula into this instrument. 

408 



OTOLARYNGOLOGY 409 

This patient did not have very much plica. Care was taken not to enter the 
pillar. I dissected down to the floor in order to free the tonsil. It was freed first 
from the anterior, then from the posterior pillar. This could be dissected either 
with a knife or scissors or dissector. The snare was inserted, screwed up, and the 
tonsil removed. It was perfectly clear that there was no more tonsil up there. The 
pillars here were intact, so that the throat contour was preserved. The muscles 
were intact. Both tonsil fossae should be dry. 

The adenoid was removed with an adenotome. By going behind the palate and 
up as far as possible what is left could be removed with the finger-nail. The patient 
was then bent forward so that the blood and whatever remained of the adenoids 
could pass out. 



DEPARTMENT OF NEUROLOGY 



SYPHILIS OF THE NERVOUS SYSTEM 
By 

Andrew H. Woods, M. D. 

The incidence of syphilis in China seems to be about the same as in Europe and 
in America, and the forms thus far encountered in this hospital indicate that the 
clinical manifestations of the disease do not vary greatly from those seen in other 
parts of the world. 

From the experience of various writers it is probable that 30 to 40 per cent of all 
necropsies would show active or healed lesions; that J to § of 1 per cent of 
general hospital patients and 1 J per cent of neurological patients have syphilitic 
lesions of the nervous system; and that 8 per cent of all syphilitics have involve- 
ment of the nervous system. 

Examination for syphilis and laboratory tests are advised in patients presenting 
the following conditions: (a) general faulty nutrition and lack of resistance in 
children and young adults; (b) hemiplegia or other vascular accidents in adults 
before middle life; (c) epilepsy starting after thirty-five; (d) headaches not other- 
wise explained. 

PATHOLOGY 

The essential lesion is an infiltration of lymphocytes and plasma cells, chiefly 
perivascular, with a tendency to the formation of new connective tissue and cap- 
illaries. Infiltrations are called gummata, if of sufficient size. The cause is the 
'Treponema pallidum discovered by Schaudin and Hoffman in 1915. The following 
are the mechanisms by which malfunctioning is produced: (a) stoppage of arteries, 
veins, or lymph channels; (b) obstruction or irritation from adhesions; (c) toxic 
effects of the virus. Disturbances then follow according to the functions of the 
structures interfered with, such as: (a) ischemia, atrophy, edema, arteritis, aneu- 
rism, and apoplexy; (b) pressure upon nerves and centers, cortical irritation, 
hydrocephalus, and tumor symptoms; (c) tract degeneration and death of nerve 
cells. 

ILLUSTRATIVE CASES 

Cases from the wards of the Union Medical College Hospital were shown as 
examples of the following types of the disease: 

A . Blocking of Peripheral Nerves by Syphilitic Infiltrations within the Nerve or in 
the Tia-Arachnoid around It, or Both 
Case 1. Male, aged forty. Alcoholic. Syphilis contracted ten years ago. Blood 
and spinal fluid Wasserman tests strongly positive. Recently suffered an attack 
of dizziness with headache. Then upper lip became weak and within a few days 
the whole musculature of the facial nerves of both sides was paralyzed. 

Attention was called to the infrequency of bilateral facial nerve paralysis as an 
isolated symptom. The condition has been observed in syphilitics. 

413 



4 i4 PEKING UNION MEDICAL COLLEGE 

B-. Infiltrations in the Meninges, Especially of the Base of the Brain 

Case 2. Male, aged about thirty. Brought into hospital a month ago in coma. 
No history. Blood and spinal fluid Wassermann tests strongly positive. Coma dis- 
appeared in a few days after salvarsan injection. 

Examination. Incomplete Argyll-Robertson pupils; complete deafness with tin- 
nitus; great excitabilty of all muscles to direct tap; no paralysis; skin and tendon 
reflexes exaggerated, no clonus, no Babinski; sphincters normal; no sensory de- 
fect except deafness. 

Case j. Male, aged thirty-seven. Brought into hospital in coma, not arousable. 
Two weeks before had had severe headache for a few hours. This recurred after ten 
days; after two or more days he vomited and sank into coma, with some sort of 
convulsion. 

Examination. Deep coma; pupils, no light reaction; movements of resistance 
with moaning when disturbed; no paralysis; muscles held slightly contracted; 
tendon reflexes exaggerated, no clonus, no Babinski; sphincters acted reflexly. 

Wassermann test of blood: at first positive, two days later, negative. Spinal 
fluid Wassermann, positive, + + + + ; polycytosis, culture negative. Died four 
days after coma began, necropsy not allowed. 

Remarks. In all of these patients (Cases i, 2, and 3) the possibility of encepha- 
litis epidemica is kept in view. A syphilitic may of course have that infection. But 
syphilis of the base of the brain can produce coma before cranial nerve palsies 
occur. This may be due to interference with the basal arteries, causing cerebral 
ischemia; or with the veins, causing edema. 

C. Infiltration into Meninges and Parenchyma of Spinal Cord (Meningo-Myelitis) 

The brain and spinal cord receive their blood supply from arteries that run in 
the membranes, small branches from which run radially into the nervous tissues. 
These small branches are easily closed by pressure of infiltrations, or by distortion 
when the membranes are drawn tense. Thus result atrophy or softening according 
to whether the ischemia is gradual or sudden. 

Case 4. Male, aged twenty-seven. Chancre in 1920. No secondaries. Wassermann 
test of blood now negative, of spinal fluid, positive, + + + + , with much globulin. 
September 7, sudden numbness in lower limbs, followed by progressive paralysis in 
them, which was complete in five days; spastic bladder sphincter; pupillary light 
reaction shown; tendon and skin reflexes absent for ten days, then returned and 
were prompt; control of bladder returned; no sensory defect; power in lower 
limbs was returning. This is the so-called "Erb type of syphilitic spinal 
paralysis." 

Case 5. Male, aged thirty-two. Much the same symptoms and findings as in 
Case 4; but this patient had a buzzing tinnitus indicating seventh nerve infiltra- 
tion, also boring pains and numbness of the left limbs, exaggerated tendon jerks 
and a Babinski plantar reflex, indicating root involvement on the left side and 
more severe breakdown of the pyramidal fibers. 

Case 6. Male aged twenty-seven. Clear syphilitic history, blood and spinal fluid 
Wassermann tests positive, + + + + • On June 2, slight premonitory weakness in 
lower limbs. Then sudden loss of power in all limbs, diaphragm, face, palate, 



NEUROLOGY 415 

pharynx, and larynx. Trismus was present. No loss of consciousness. Cheyne- 
Stokes respiration followed, then pneumonia. 

Tendon jerks now exaggerated, clonus and Babinski present. Explosions of out- 
ward expressions of weeping or laughing on slight provocation. Under vigorous 
antisyphilitic treatment he recovered 50 per cent of the lost power. 

Remarks. In Cases 4 and 5 the lesions were largely spinal, while the patient in 
Case 6 had a lesion involving the medulla oblongata and lower pons. In all three 
patients the pyramidal tracts were injured at the different levels respectively 
involved. In all three the motor nuclei suffered, but later showed considerable 
recovery. The lesions were probably thrombotic, but possibly due only to closure 
of vessels by pressure. 

D. Degeneration of Afferent 'Tracts. Tabes Dorsalis. Pseudo-Tabes 

Polyneuritis and the early root lesions of syphilis sometimes give symptoms in- 
distinguishable from those of tabes dorsalis. The diagnosis is madewhen the former 
are cured by appropriate therapy. The degenerated tracts of true tabes cannot be 
restored. 

Definition of Tabes Dorsalis. A syphilitic disease of the nervous system marked 
by degeneration of the afferent tracts with resulting characteristic pains, loss of 
pupillary light reflex and tendon reflexes, and often of co-ordinated muscle move- 
ments. 

Those most commonly affected are the dorsal tracts of the spinal cord, then the 
optic tracts, less frequently the sensory tracts of the fifth, eighth, ninth, tenth, 
and eleventh cranial nerves. 

The mechanism may be: {a) constriction of the root by newly-formed connec- 
tive tissue; (b) selective action of a toxin to which the afferent tracts are sensitive. 

Four cardinal symptoms are: shooting pains and crises, loss of tendon reflexes, 
irregularities in shape and reactions of pupils, and ataxia. Five other commonly 
found symptoms are: hypotonus of muscles, objective sensory defects, loss of 
sphincter control, loss of sexual feeling and reflexes, and trophic changes. 

Case 7. Laboratory evidence positive; shooting pains five years, Argyll-Robert- 
son pupils, no ataxia, tendon jerks lost, loss of sphincter control, loss of sexual feel- 
ings and capacity, objective sensory defects, vitiligo, and a Charcot knee-joint. 

Case 8. Chancre five years ago, laboratory findings now negative; irregular 
pupils, partial Argyll-Robertson sign, loss of tendon jerks, loss of vibratory sense, 
loss of sexual feeling, vitiligo, and a Charcot knee-joint. 

E. Destruction of the Brain Cortex. Paretic Dementia 
Paretic dementia is a syphilitic disease of the nervous system marked primarily 
by atrophy of the cortical nerve-cells and in addition by more or less general nerve 
fiber and cell destruction throughout the nervous system. 

The usual symptoms are: gradual reduction of the man to a vegetative automa- 
ton; irregular increase or decrease in tendon and skin reflexes, tremors, together 
with sensory and eye changes, such as mark tabes dorsalis. 

Case. 9. History and laboratory findings of syphilis. Shooting pains, irregular 
pupils with Argyll-Robertson reflexes, tendon reflexes prompt in some parts, re- 



4i 6 PEKING UNION MEDICAL COLLEGE 

duced in others, overexcitable sexually. Euphoria, loquacity, meddlesomeness, 
deterioration of judgment, and insomnia, are present. 

Case 10. Aged thirty-seven. History and laboratory proofs of syphilis were posi- 
tive. Argyll-Robertson pupils, blank face, coarse tremors, speech inarticulate, 
marked general ataxia, muscles feeble; exaggerated tendon reflexes, except right 
Achilles reflex, which was absent; Babinski present. 

TREATMENT 

The diagnosis must be made early and vigorous treatment started at once, 
otherwise permanent degenerations rapidly occur. 

Intravenous salvarsan, 0.400 gram at first, increased to 0.700 or more. This may 
be continued every fifth day for six weeks, together with mercury. Its effectiveness 
should be checked by blood and spinal fluid tests at the end of each six weeks. A 
rest from treatment may then be allowed for from four to six weeks. This plan 
should be followed until symptoms and positive laboratory findings are absent, 
then less vigorous treatment should be given for two years. 

Intraspinal treatment seems inadvisable for the following reasons: 

1. Results thus far in patients who were not simultaneously receiving intra- 
venous treatment do not show any verifiable advantage in the method. 

1. The intraspinal dose is too small to produce results, being only \ of 1 per 
cent of the ordinary dose as given intravenously. 

3. Salvarsan given through the blood-stream reaches every living cell in the 
parenchyma of the nervous system. The spinal fluid bathes only the external lin- 
ing-cells of the membranes, and is rapidly drained back into the venous system. 
Medicine thrown into it cannot be expected to affect cells within the brain and 
spinal cord any more than medicines in the peritoneal fluid would affect a gumma 
of the liver. 






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